Provider Demographics
NPI:1104540491
Name:PEPER, KELLY LYNNE (RD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNNE
Last Name:PEPER
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 1:832 E POWELL WAY
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85249-3012
Mailing Address - Country:US
Mailing Address - Phone:480-296-9633
Mailing Address - Fax:
Practice Address - Street 1:1840 E BROADWAY RD
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-1614
Practice Address - Country:US
Practice Address - Phone:602-243-7277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-29
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1051673133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered