Provider Demographics
NPI:1619620127
Name:BAKER, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BAKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4365 E PECOS RD STE 131
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-8052
Mailing Address - Country:US
Mailing Address - Phone:602-318-5965
Mailing Address - Fax:
Practice Address - Street 1:4365 E PECOS RD STE 131
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-8052
Practice Address - Country:US
Practice Address - Phone:602-318-5965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-03
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist