Provider Demographics
NPI:1184228249
Name:SANNA-GOUIN, KELLY (RD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SANNA-GOUIN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2283 SHEVLIN ST
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-1176
Mailing Address - Country:US
Mailing Address - Phone:248-310-0257
Mailing Address - Fax:
Practice Address - Street 1:2283 SHEVLIN ST
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220-1176
Practice Address - Country:US
Practice Address - Phone:248-310-0257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-29
Last Update Date:2020-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered