Provider Demographics
NPI:1346555703
Name:DOMINICK, KELLI (MED, LD, RD, CDE)
Entity Type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:
Last Name:DOMINICK
Suffix:
Gender:F
Credentials:MED, LD, RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 S CYPRESS ST
Mailing Address - Street 2:
Mailing Address - City:VIVIAN
Mailing Address - State:LA
Mailing Address - Zip Code:71082-3206
Mailing Address - Country:US
Mailing Address - Phone:318-375-2356
Mailing Address - Fax:
Practice Address - Street 1:712 S CYPRESS ST
Practice Address - Street 2:
Practice Address - City:VIVIAN
Practice Address - State:LA
Practice Address - Zip Code:71082-3206
Practice Address - Country:US
Practice Address - Phone:318-375-2356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-10
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT05308133N00000X, 133NN1002X, 133V00000X, 133VN1004X, 133VN1005X, 133VN1006X
LA1270133N00000X, 133NN1002X, 133V00000X, 133VN1004X, 133VN1005X, 133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic