Provider Demographics
NPI:1174781967
Name:FREDERICK, KELLI (RD)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 W WOODWAY AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99218-2663
Mailing Address - Country:US
Mailing Address - Phone:509-921-6560
Mailing Address - Fax:
Practice Address - Street 1:11703 E SPRAGUE AVE
Practice Address - Street 2:BLDG C-3
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-6128
Practice Address - Country:US
Practice Address - Phone:509-921-6560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-28
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00001335133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9051731Medicaid
WADI00001335OtherWA CERTIFICATION NUMBER
WA8293979OtherPROVIDER NUMBER
WA887397OtherADA NUMBER
WA9051731Medicaid