Provider Demographics
NPI:1629523782
Name:MILLER, KELLY (R D)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:R D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:295 S CHIPETA WAY
Mailing Address - Street 2:SUITE 248
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1287
Mailing Address - Country:US
Mailing Address - Phone:801-213-3778
Mailing Address - Fax:801-587-3001
Practice Address - Street 1:295 S CHIPETA WAY
Practice Address - Street 2:SUITE 248
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1287
Practice Address - Country:US
Practice Address - Phone:801-213-3778
Practice Address - Fax:801-587-3001
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-18
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3637234901133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered