Healthcare Provider Details

I. General information

NPI: 1831276245
Provider Name (Legal Business Name): NANCY JANE KELLER RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 FOOTHILL BLVD NUTRITION & FOOD SERVICE (120)
SALT LAKE CITY UT
84148-0001
US

IV. Provider business mailing address

500 FOOTHILL BLVD NUTRITION & FOOD SERVICE (120)
SALT LAKE CITY UT
84148-0001
US

V. Phone/Fax

Practice location:
  • Phone: 801-582-1565
  • Fax: 801-584-2597
Mailing address:
  • Phone: 801-582-1565
  • Fax: 801-584-2597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number6311075-4901
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberR380304
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: