Provider Demographics
NPI:1265838429
Name:PHIPPEN, KELSEY (RD, LD, LMNT)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:PHIPPEN
Suffix:
Gender:F
Credentials:RD, LD, LMNT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 BAYBERRY CIR
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-5401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1745 MADISON AVE
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-5249
Practice Address - Country:US
Practice Address - Phone:712-322-9260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-14
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA075686133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered