Provider Demographics
NPI:1073746731
Name:BURGESS, KELLY (MBA, RD, LDN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BURGESS
Suffix:
Gender:F
Credentials:MBA, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:894 HARDINGVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MONROEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08343-2714
Mailing Address - Country:US
Mailing Address - Phone:609-352-6266
Mailing Address - Fax:888-266-9161
Practice Address - Street 1:894 HARDINGVILLE RD
Practice Address - Street 2:
Practice Address - City:MONROEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08343-2714
Practice Address - Country:US
Practice Address - Phone:609-352-6266
Practice Address - Fax:888-266-9161
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-28
Last Update Date:2013-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN004174133V00000X
NJ133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered