Provider Demographics
NPI:1700414885
Name:WEBB, KELLI JO (RD, LD, CDE)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:JO
Last Name:WEBB
Suffix:
Gender:F
Credentials:RD, LD, CDE
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:JO
Other - Last Name:SOUTHARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD, CDE
Mailing Address - Street 1:17405 WISEMAN DR
Mailing Address - Street 2:
Mailing Address - City:PFLUGERVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78660-5723
Mailing Address - Country:US
Mailing Address - Phone:512-461-7741
Mailing Address - Fax:
Practice Address - Street 1:911 W 38TH ST STE 201
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1107
Practice Address - Country:US
Practice Address - Phone:512-459-1131
Practice Address - Fax:512-459-0846
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-01
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT84535133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered