Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 736 | WY |
NPI | 1619219607 |
---|---|
Provider Name | Kaly Sellers |
First Address | Afton, WY 83110-9739 |
Second Address | Afton, WY 83110-9739 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/03/2013 |
Last Update Date | 18/03/2013 |