Provider Demographics
NPI:1558813832
Name:KOSWICK, KELLIE (RD, CLC)
Entity Type:Individual
Prefix:MS
First Name:KELLIE
Middle Name:
Last Name:KOSWICK
Suffix:
Gender:F
Credentials:RD, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 LINCOLN ST
Mailing Address - Street 2:CS 4200
Mailing Address - City:FORT MORGAN
Mailing Address - State:CO
Mailing Address - Zip Code:80701-3290
Mailing Address - Country:US
Mailing Address - Phone:970-542-3321
Mailing Address - Fax:970-867-7972
Practice Address - Street 1:1000 LINCOLN ST
Practice Address - Street 2:CS 4200
Practice Address - City:FORT MORGAN
Practice Address - State:CO
Practice Address - Zip Code:80701-3290
Practice Address - Country:US
Practice Address - Phone:970-542-3321
Practice Address - Fax:970-867-7972
Is Sole Proprietor?:No
Enumeration Date:2016-11-02
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO86020817133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered