Provider Demographics
NPI:1285447029
Name:MANTOOTH, KELLI (RD)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:MANTOOTH
Suffix:
Gender:
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2518 LELARAY ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-2405
Mailing Address - Country:US
Mailing Address - Phone:208-703-1850
Mailing Address - Fax:
Practice Address - Street 1:3724 JEFFERSON ST STE 104
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-6204
Practice Address - Country:US
Practice Address - Phone:208-703-1850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-27
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered