Provider Demographics
NPI:1417665589
Name:GANTOUS, KELLY ANN (RDN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:GANTOUS
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5761 E PALM OASIS ST
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92264-6430
Mailing Address - Country:US
Mailing Address - Phone:760-835-5768
Mailing Address - Fax:
Practice Address - Street 1:5761 E PALM OASIS ST
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92264-6430
Practice Address - Country:US
Practice Address - Phone:760-835-5768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-08
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered