Basic Information
| Provider Information | |||||||||
| NPI: | 1558462341 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHELTON | ||||||||
| FirstName: | KELLI | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | R.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 705 SE INDIAN RD | ||||||||
| Address2: | |||||||||
| City: | IDABEL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 747456439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802083838 | ||||||||
| FaxNumber: | 5802861087 | ||||||||
| Practice Location | |||||||||
| Address1: | 902 E LINCOLN RD | ||||||||
| Address2: | |||||||||
| City: | IDABEL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 747457337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802862600 | ||||||||
| FaxNumber: | 5802861087 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 1452 | OK | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.