Provider Demographics
NPI:1982366035
Name:GROVER, KELLI J (RDN)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:J
Last Name:GROVER
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31820 S POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:WITTMANN
Mailing Address - State:AZ
Mailing Address - Zip Code:85361-9439
Mailing Address - Country:US
Mailing Address - Phone:719-290-0002
Mailing Address - Fax:
Practice Address - Street 1:314 W 300 S STE 222
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84101-2038
Practice Address - Country:US
Practice Address - Phone:719-290-0002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX86067347133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered