Healthcare Provider Details

I. General information

NPI: 1346489218
Provider Name (Legal Business Name): KELLY SHEPPARD LOUGHLIN- MS, RDN, CDCES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY SHEPPARD LOUGHLIN MS, RDN, CDCES

II. Dates (important events)

Enumeration Date: 02/16/2009
Last Update Date: 03/07/2020
Certification Date: 03/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18865 VISTA PORTOLA
TRABUCO CANYON CA
92679-1101
US

IV. Provider business mailing address

18865 VISTA PORTOLA
TRABUCO CANYON CA
92679-1101
US

V. Phone/Fax

Practice location:
  • Phone: 760-641-4129
  • Fax: 760-641-4129
Mailing address:
  • Phone: 760-641-4129
  • Fax: 760-641-4129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number2031-0259
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number852172
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number852172
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: