Provider Demographics
NPI:1346489218
Name:LOUGHLIN-, KELLY SHEPPARD (MS, RDN, CDCES)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:SHEPPARD
Last Name:LOUGHLIN-
Suffix:
Gender:F
Credentials:MS, RDN, CDCES
Other - Prefix:MRS
Other - First Name:KELLY
Other - Middle Name:SHEPPARD
Other - Last Name:LOUGHLIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, RDN, CDCES
Mailing Address - Street 1:18865 VISTA PORTOLA
Mailing Address - Street 2:
Mailing Address - City:TRABUCO CANYON
Mailing Address - State:CA
Mailing Address - Zip Code:92679-1101
Mailing Address - Country:US
Mailing Address - Phone:760-641-4129
Mailing Address - Fax:760-641-4129
Practice Address - Street 1:18865 VISTA PORTOLA
Practice Address - Street 2:
Practice Address - City:TRABUCO CANYON
Practice Address - State:CA
Practice Address - Zip Code:92679-1101
Practice Address - Country:US
Practice Address - Phone:760-641-4129
Practice Address - Fax:760-641-4129
Is Sole Proprietor?:No
Enumeration Date:2009-02-16
Last Update Date:2020-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2031-0259133NN1002X
TX852172133V00000X
CA852172133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2031-0259OtherCDE
CA852172OtherCDR