Healthcare Provider Details

I. General information

NPI: 1346555703
Provider Name (Legal Business Name): KELLI DOMINICK M.ED., LD, RD, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2010
Last Update Date: 08/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 S CYPRESS ST
VIVIAN LA
71082-3206
US

IV. Provider business mailing address

712 S CYPRESS ST
VIVIAN LA
71082-3206
US

V. Phone/Fax

Practice location:
  • Phone: 318-375-2356
  • Fax:
Mailing address:
  • Phone: 318-375-2356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberDT05308
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number1270
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberDT05308
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number1270
License Number StateLA
# 5
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT05308
License Number StateTX
# 6
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1270
License Number StateLA
# 7
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License NumberDT05308
License Number StateTX
# 8
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number1270
License Number StateLA
# 9
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License NumberDT05308
License Number StateTX
# 10
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number1270
License Number StateLA
# 11
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License NumberDT05308
License Number StateTX
# 12
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number1270
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: