Provider Demographics
NPI:1073778189
Name:KNISLEY, KELLY J (MS RD CSO LD)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:J
Last Name:KNISLEY
Suffix:
Gender:F
Credentials:MS RD CSO LD
Other - Prefix:MRS
Other - First Name:KELLY
Other - Middle Name:J
Other - Last Name:POLLANDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS RD LD
Mailing Address - Street 1:ONE CHILDREN'S PLAZA
Mailing Address - Street 2:DAYTON CHILDRENS HOSPITAL
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45404
Mailing Address - Country:US
Mailing Address - Phone:937-641-3000
Mailing Address - Fax:937-641-5909
Practice Address - Street 1:1141 N MONROE DR
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-1619
Practice Address - Country:US
Practice Address - Phone:937-352-2377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-29
Last Update Date:2017-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3331133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered