MEDICARE: KELLY RENEE ROBERS RD, CDCES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	86023868	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	86023868	OTHER	AZ	LICENSE

General Provider Information

NPI Number	:	1851799357
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY RENEE ROBERS RD, CDCES

Provider Business Mailing Address
First Line	:	15212 N 2ND ST STE 4020
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85022-3610
Country	:	US
Telephone Number	:	602-935-8791
Fax Number	:	833-441-1808

Provider Business Practice Location Address
First Line	:	15212 N 2ND ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85022-3610
Country	:	US
Telephone Number	:	708-469-9252
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/15/2014
Last Update Date	:	11/23/2021

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Directions to “ KELLY RENEE ROBERS RD, CDCES” Practice Location

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