MEDICARE: MRS. KELLI RAE JENNINGS R.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1083630800
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLI RAE JENNINGS R.D.

Provider Business Mailing Address
First Line	:	142 SHAVANO ST
Second Line	:	PO BOX 2074
City	:	CRESTED BUTTE
State	:	CO
Zip	:	81224-9621
Country	:	US
Telephone Number	:	970-349-0767
Fax Number	:	970-349-1251

Provider Business Practice Location Address
First Line	:	142 SHAVANO ST
Second Line	:
City	:	CRESTED BUTTE
State	:	CO
Zip	:	81224-9621
Country	:	US
Telephone Number	:	970-349-0767
Fax Number	:	970-349-1251

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/14/2006
Last Update Date	:	07/08/2007

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