Provider Demographics
NPI:1972051134
Name:WARNER, KELLY B (MPH, RDN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:B
Last Name:WARNER
Suffix:
Gender:F
Credentials:MPH, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1328 S BUNDY DR APT 1
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1338
Mailing Address - Country:US
Mailing Address - Phone:408-621-0329
Mailing Address - Fax:
Practice Address - Street 1:1328 S BUNDY DR APT 1
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1338
Practice Address - Country:US
Practice Address - Phone:408-621-0329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-16
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered