Provider Demographics
NPI:1851799357
Name:ROBERS, KELLY RENEE (RD, CDCES)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:RENEE
Last Name:ROBERS
Suffix:
Gender:F
Credentials:RD, CDCES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15212 N 2ND ST STE 4020
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-3610
Mailing Address - Country:US
Mailing Address - Phone:602-935-8791
Mailing Address - Fax:833-441-1808
Practice Address - Street 1:15212 N 2ND ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-3610
Practice Address - Country:US
Practice Address - Phone:708-469-9252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-15
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ86023868133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ86023868OtherLICENSE