MEDICARE: MRS. KELLY SHEPPARD LOUGHLIN- MS, RDN, CDCES

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	133NN1002X	Nutrition Education Nutritionist	2031-0259	CA
2	133V00000X	Registered Dietitian	852172	TX
3	133V00000X	Registered Dietitian	852172	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2031-0259	OTHER	CA	CDE
2	852172	OTHER	CA	CDR

General Provider Information

NPI Number	:	1346489218
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLY SHEPPARD LOUGHLIN- MS, RDN, CDCES

Provider Business Mailing Address
First Line	:	18865 VISTA PORTOLA
Second Line	:
City	:	TRABUCO CANYON
State	:	CA
Zip	:	92679-1101
Country	:	US
Telephone Number	:	760-641-4129
Fax Number	:	760-641-4129

Provider Business Practice Location Address
First Line	:	18865 VISTA PORTOLA
Second Line	:
City	:	TRABUCO CANYON
State	:	CA
Zip	:	92679-1101
Country	:	US
Telephone Number	:	760-641-4129
Fax Number	:	760-641-4129

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

Provider Enumeration Date	:	02/16/2009
Last Update Date	:	03/07/2020

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