Provider Demographics
NPI:1902816150
Name:KELLER, JULIE KATHERINE (MS RD CDE)
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:KATHERINE
Last Name:KELLER
Suffix:
Gender:F
Credentials:MS RD CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 LINDA LN
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-1256
Mailing Address - Country:US
Mailing Address - Phone:509-758-1741
Mailing Address - Fax:208-843-9406
Practice Address - Street 1:111 BEVER GRADE
Practice Address - Street 2:
Practice Address - City:LAPWAI
Practice Address - State:ID
Practice Address - Zip Code:83540
Practice Address - Country:US
Practice Address - Phone:208-843-2271
Practice Address - Fax:208-843-9406
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-265133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P9597Medicare UPIN
ID872036-8T2044Medicare ID - Type Unspecified