Provider Demographics
NPI:1629681614
Name:NIEMEYER, KEELY ALISON (RD)
Entity Type:Individual
Prefix:
First Name:KEELY
Middle Name:ALISON
Last Name:NIEMEYER
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 1:35775 DAMASCUS ST
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-5113
Mailing Address - Country:US
Mailing Address - Phone:909-289-2403
Mailing Address - Fax:
Practice Address - Street 1:33758 YUCAIPA BLVD
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-2243
Practice Address - Country:US
Practice Address - Phone:909-795-9747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86070249133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered