Provider Demographics
NPI:1790080893
Name:BERNIER, KELSEY LORRAINE (MS, RD, LD, LMT)
Entity Type:Individual
Prefix:MRS
First Name:KELSEY
Middle Name:LORRAINE
Last Name:BERNIER
Suffix:
Gender:F
Credentials:MS, RD, LD, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:305 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6231
Practice Address - Country:US
Practice Address - Phone:208-381-7340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-20
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-403225700000X
IDD-1022133V00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist