Provider Demographics
NPI:1679757108
Name:VAN HORN, KELLY DENISE (RD)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:DENISE
Last Name:VAN HORN
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:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:1124 COLUMBIA ST STE 400
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-2053
Practice Address - Country:US
Practice Address - Phone:206-215-2440
Practice Address - Fax:206-215-2457
Is Sole Proprietor?:No
Enumeration Date:2007-12-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00001827133N00000X, 133V00000X
WAHC00152963133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist