Provider Demographics
NPI:1790288124
Name:OTOOLE WOOD, KELLY KATHLEEN (RDN, LDN)
Entity Type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:KATHLEEN
Last Name:OTOOLE WOOD
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:KATHLEEN
Other - Last Name:O'TOOLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD
Mailing Address - Street 1:13447 N 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83714-9409
Mailing Address - Country:US
Mailing Address - Phone:208-407-8921
Mailing Address - Fax:208-694-7837
Practice Address - Street 1:6126 W STATE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-2741
Practice Address - Country:US
Practice Address - Phone:208-407-8921
Practice Address - Fax:208-694-7837
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-12
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-460133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered