Provider Demographics
NPI:1457977159
Name:KEPHART, KASIE (MS, LDN, CCN)
Entity Type:Individual
Prefix:
First Name:KASIE
Middle Name:
Last Name:KEPHART
Suffix:
Gender:F
Credentials:MS, LDN, CCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4111 N DRINKWATER BLVD APT F208
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-3683
Mailing Address - Country:US
Mailing Address - Phone:815-701-6157
Mailing Address - Fax:
Practice Address - Street 1:4111 N DRINKWATER BLVD APT F208
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-3683
Practice Address - Country:US
Practice Address - Phone:815-701-6157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-18
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.007331133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist