Basic Information
| Provider Information | |||||||||
| NPI: | 1508511122 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALL | ||||||||
| FirstName: | KELLI | ||||||||
| MiddleName: | CIERRA | ||||||||
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| Credential: | RDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13901 E JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482152720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138212591 | ||||||||
| FaxNumber: | 3138220950 | ||||||||
| Practice Location | |||||||||
| Address1: | 13901 E JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482152720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138212591 | ||||||||
| FaxNumber: | 3138220950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2022 | ||||||||
| LastUpdateDate: | 02/14/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 86044997 | MI | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.