Basic Information
Provider Information | |||||||||
NPI: | 1649545526 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KERR | ||||||||
FirstName: | KARLEE | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | RDN, LD, CD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MILLER | ||||||||
OtherFirstName: | KARLEE | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RD,LD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1515 E COLUMBIA ST | ||||||||
Address2: |   | ||||||||
City: | OTHELLO | ||||||||
State: | WA | ||||||||
PostalCode: | 993441846 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5094885256 | ||||||||
FaxNumber: | 5094889939 | ||||||||
Practice Location | |||||||||
Address1: | 1515 E COLUMBIA ST | ||||||||
Address2: |   | ||||||||
City: | OTHELLO | ||||||||
State: | WA | ||||||||
PostalCode: | 993441846 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5094885256 | ||||||||
FaxNumber: | 5094889939 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/12/2012 | ||||||||
LastUpdateDate: | 02/17/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/17/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | D160321502 | WA | Y |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   |
ID Information
ID | Type | State | Issuer | Description | 2089525 | 05 | WA |   | MEDICAID |