Provider Demographics
NPI:1073237079
Name:LAVERY, KIELY (RDN, LDN)
Entity Type:Individual
Prefix:
First Name:KIELY
Middle Name:
Last Name:LAVERY
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6180 N CAMINO PADRE ISIDORO
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85718-4023
Mailing Address - Country:US
Mailing Address - Phone:520-360-5338
Mailing Address - Fax:520-300-7033
Practice Address - Street 1:6180 N CAMINO PADRE ISIDORO
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85718-4023
Practice Address - Country:US
Practice Address - Phone:520-360-5338
Practice Address - Fax:520-300-7033
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-03
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND9411133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered