Provider Demographics
NPI:1841038858
Name:KOPPENAL, KELLY ETEMADIPOUR (NBCHWC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ETEMADIPOUR
Last Name:KOPPENAL
Suffix:
Gender:F
Credentials:NBCHWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 LONGHILL RD
Mailing Address - Street 2:
Mailing Address - City:GOODE
Mailing Address - State:VA
Mailing Address - Zip Code:24556-2209
Mailing Address - Country:US
Mailing Address - Phone:973-885-3709
Mailing Address - Fax:
Practice Address - Street 1:203 LONGHILL RD
Practice Address - Street 2:
Practice Address - City:GOODE
Practice Address - State:VA
Practice Address - Zip Code:24556-2209
Practice Address - Country:US
Practice Address - Phone:973-885-3709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-16
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X, 133NN1002X
A-3650883171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education