Provider Demographics
NPI:1740409044
Name:VIVATSON, KELLI ANN (LRD)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:ANN
Last Name:VIVATSON
Suffix:
Gender:F
Credentials:LRD
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:ANN
Other - Last Name:VIVASTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 6002
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58206-6002
Mailing Address - Country:US
Mailing Address - Phone:701-780-5000
Mailing Address - Fax:701-780-1942
Practice Address - Street 1:1200 S COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4036
Practice Address - Country:US
Practice Address - Phone:701-780-5000
Practice Address - Fax:701-780-1942
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND700133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered