Provider Demographics
NPI:1578949053
Name:KLINE-CUNNINGHAM, KELLY (RDN,CD,CNSC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KLINE-CUNNINGHAM
Suffix:
Gender:F
Credentials:RDN,CD,CNSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:435-635-6500
Mailing Address - Fax:435-635-6549
Practice Address - Street 1:320 E 600 S
Practice Address - Street 2:INTERMOUNTAIN MEDICAL GROUP
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-3949
Practice Address - Country:US
Practice Address - Phone:435-688-4850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-06
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT803082133V00000X
UT9461538-4901133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered