Provider Demographics
NPI:1619316791
Name:PANGBORN, KERI LYNN (RD)
Entity Type:Individual
Prefix:MS
First Name:KERI
Middle Name:LYNN
Last Name:PANGBORN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:FILION
Mailing Address - State:MI
Mailing Address - Zip Code:48432-9781
Mailing Address - Country:US
Mailing Address - Phone:989-450-8555
Mailing Address - Fax:
Practice Address - Street 1:210 S FIRST ST
Practice Address - Street 2:
Practice Address - City:HARBOR BEACH
Practice Address - State:MI
Practice Address - Zip Code:48441
Practice Address - Country:US
Practice Address - Phone:989-479-3201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-21
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1015699133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered