Provider Demographics
NPI:1720704810
Name:KELLER, ROSA MOON (PHD, RD)
Entity Type:Individual
Prefix:
First Name:ROSA
Middle Name:MOON
Last Name:KELLER
Suffix:
Gender:F
Credentials:PHD, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 SCOTT ST APT 305
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94123-3396
Mailing Address - Country:US
Mailing Address - Phone:541-226-8188
Mailing Address - Fax:
Practice Address - Street 1:3101 SCOTT ST APT 305
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94123-3396
Practice Address - Country:US
Practice Address - Phone:541-226-8188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-19
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X, 133NN1002X, 133VN1004X, 133VN1005X, 133VN1201X, 133VN1501X
CA86210639133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight Management
No133VN1501XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Sports Dietetics