Provider Demographics
NPI:1578172581
Name:STEVENS, KESHELE ELIZABETH (RDN)
Entity Type:Individual
Prefix:
First Name:KESHELE
Middle Name:ELIZABETH
Last Name:STEVENS
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 1:461 S STIRLING DR
Mailing Address - Street 2:
Mailing Address - City:FRUIT HEIGHTS
Mailing Address - State:UT
Mailing Address - Zip Code:84037-2325
Mailing Address - Country:US
Mailing Address - Phone:385-405-6810
Mailing Address - Fax:
Practice Address - Street 1:461 S STIRLING DR
Practice Address - Street 2:
Practice Address - City:FRUIT HEIGHTS
Practice Address - State:UT
Practice Address - Zip Code:84037-2325
Practice Address - Country:US
Practice Address - Phone:385-405-6810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-26
Last Update Date:2020-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11837645-4901133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered