Provider Demographics
NPI:1255655569
Name:TSOUGAS, KELLY V (MS, RD, LDN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:V
Last Name:TSOUGAS
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5410 S ASHCROFT WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6866
Mailing Address - Country:US
Mailing Address - Phone:919-601-3919
Mailing Address - Fax:919-705-1626
Practice Address - Street 1:5410 S ASHCROFT WAY
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6866
Practice Address - Country:US
Practice Address - Phone:919-601-3919
Practice Address - Fax:919-705-1626
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-16
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2713133V00000X
NV40194-DI-0133V00000X
IL164008832133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered