Provider Demographics
NPI:1619937604
Name:KEPPEN, BRIAN A (RD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:A
Last Name:KEPPEN
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 1:1222 E WOODLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BARRON
Mailing Address - State:WI
Mailing Address - Zip Code:54812-1765
Mailing Address - Country:US
Mailing Address - Phone:715-838-5222
Mailing Address - Fax:
Practice Address - Street 1:1222 E WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:BARRON
Practice Address - State:WI
Practice Address - Zip Code:54812-1765
Practice Address - Country:US
Practice Address - Phone:715-838-5222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1572133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0090 05080Medicare ID - Type Unspecified