Provider Demographics
NPI:1891368452
Name:MELLOTT, KIRSTEN NICOLE (RDN)
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:NICOLE
Last Name:MELLOTT
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:KIRSTEN
Other - Middle Name:NICOLE
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN
Mailing Address - Street 1:1205 N F AVE
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:AZ
Mailing Address - Zip Code:85607-1920
Mailing Address - Country:US
Mailing Address - Phone:520-364-1429
Mailing Address - Fax:520-515-8690
Practice Address - Street 1:155 CALLE PORTAL STE 700
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2973
Practice Address - Country:US
Practice Address - Phone:520-459-0203
Practice Address - Fax:520-459-3159
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-21
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ86154717133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered