Provider Demographics
NPI:1457370314
Name:KHADER, HEATHER L
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:L
Last Name:KHADER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:L
Other - Last Name:GOUDELOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1200 E 3900 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1300
Mailing Address - Country:US
Mailing Address - Phone:801-268-7860
Mailing Address - Fax:
Practice Address - Street 1:1200 E 3900 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1300
Practice Address - Country:US
Practice Address - Phone:801-268-7860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT60049814901133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education