Individual
KELLY ETEMADIPOUR KOPPENAL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
NBCHWC
Contact information
Practice address
203 LONGHILL RD, GOODE, VA 24556-2209
(973) 885-3709
Mailing address
203 LONGHILL RD, GOODE, VA 24556-2209
(973) 885-3709
Taxonomy
Speciality
Code
Description
License number
State
133N00000X
Nutritionist
—
—
133NN1002X
Nutrition Education Nutritionist
—
—
171400000X
Health & Wellness Coach
Primary
A-3650883
—
Other
Enumeration date
07/16/2024
Last updated
07/16/2024
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