Basic Information
| Provider Information | |||||||||
| NPI: | 1770695645 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EZELL | ||||||||
| FirstName: | KELLEY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29057 FOGHORN CT | ||||||||
| Address2: | |||||||||
| City: | ROMOLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925853179 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11201 BENTON ST | ||||||||
| Address2: | (120) | ||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923571000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098257084 | ||||||||
| FaxNumber: | 9094223108 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.