Provider Demographics
NPI:1053462804
Name:NIBLETT, KELLY IRENE (RD)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:IRENE
Last Name:NIBLETT
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:IRENE
Other - Last Name:PELCHAT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:3138 N BOSWELL TER
Mailing Address - Street 2:
Mailing Address - City:HERNANDO
Mailing Address - State:FL
Mailing Address - Zip Code:34442-4732
Mailing Address - Country:US
Mailing Address - Phone:352-746-3862
Mailing Address - Fax:352-795-8409
Practice Address - Street 1:6201 N SUNCOAST BLVD
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34428-6712
Practice Address - Country:US
Practice Address - Phone:352-795-6560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND4304133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered