Provider Demographics
NPI:1689181364
Name:RAAB, KELSEY MARIE
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:MARIE
Last Name:RAAB
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 1:904 E DONLIN ST
Mailing Address - Street 2:
Mailing Address - City:MILLER
Mailing Address - State:SD
Mailing Address - Zip Code:57362-1654
Mailing Address - Country:US
Mailing Address - Phone:605-870-1036
Mailing Address - Fax:605-853-2305
Practice Address - Street 1:300 W 5TH ST
Practice Address - Street 2:
Practice Address - City:MILLER
Practice Address - State:SD
Practice Address - Zip Code:57362-1238
Practice Address - Country:US
Practice Address - Phone:605-853-2421
Practice Address - Fax:605-853-0333
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-04
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0614133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered