Provider Demographics
NPI:1356758189
Name:CONYERS, KACEY ELIZABETH (MS, RD, LD)
Entity type:Individual
Prefix:
First Name:KACEY
Middle Name:ELIZABETH
Last Name:CONYERS
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1270 KOTNUM RD
Mailing Address - Street 2:
Mailing Address - City:WARM SPRINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97761
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:541-553-2457
Practice Address - Street 1:1270 KOTNUM RD
Practice Address - Street 2:
Practice Address - City:WARM SPRINGS
Practice Address - State:OR
Practice Address - Zip Code:97761
Practice Address - Country:US
Practice Address - Phone:541-553-1196
Practice Address - Fax:541-553-2457
Is Sole Proprietor?:No
Enumeration Date:2014-07-14
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLD-D-10163387133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered