Healthcare Provider Details

I. General information

NPI: 1407437544
Provider Name (Legal Business Name): KERRY THUETT FNTP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2021
Last Update Date: 04/20/2021
Certification Date: 04/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 MEMPHIS DR
LUBBOCK TX
79423-3618
US

IV. Provider business mailing address

9000 MEMPHIS DR
LUBBOCK TX
79423-3618
US

V. Phone/Fax

Practice location:
  • Phone: 510-909-5461
  • Fax:
Mailing address:
  • Phone: 510-909-5461
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: