Healthcare Provider Details

I. General information

NPI: 1811228364
Provider Name (Legal Business Name): KELLI ANNE LYTLE RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2010
Last Update Date: 01/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 WALLACE WAY
GRANDVIEW WA
98930-8805
US

IV. Provider business mailing address

1000 WALLACE WAY
GRANDVIEW WA
98930-8805
US

V. Phone/Fax

Practice location:
  • Phone: 509-882-4707
  • Fax:
Mailing address:
  • Phone: 509-882-4707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI 60131542
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: