Provider Demographics
NPI:1831895796
Name:YOUNG, KELSEY MARIE (CNC)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:MARIE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:CNC
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:MARIE
Other - Last Name:GOGARTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNC
Mailing Address - Street 1:3076 PALM ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-5005
Mailing Address - Country:US
Mailing Address - Phone:650-759-0617
Mailing Address - Fax:
Practice Address - Street 1:3076 PALM ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104-5005
Practice Address - Country:US
Practice Address - Phone:650-759-0617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education