Healthcare Provider Details

I. General information

NPI: 1851967228
Provider Name (Legal Business Name): KELSEY HOJARA RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2021
Last Update Date: 05/27/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1702 S BUFFSTONE CT
BLOOMINGTON IN
47401-7703
US

IV. Provider business mailing address

1702 S BUFFSTONE CT
BLOOMINGTON IN
47401-7703
US

V. Phone/Fax

Practice location:
  • Phone: 574-329-4326
  • Fax:
Mailing address:
  • Phone: 574-329-4326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number37003084A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: