Provider Demographics
NPI:1073941688
Name:KELLY, MARJORIE (RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:MARJORIE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 W LOCKWOOD AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:WEBSTER GROVES
Mailing Address - State:MO
Mailing Address - Zip Code:63119-2951
Mailing Address - Country:US
Mailing Address - Phone:314-737-4070
Mailing Address - Fax:314-737-4071
Practice Address - Street 1:231 W LOCKWOOD AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:WEBSTER GROVES
Practice Address - State:MO
Practice Address - Zip Code:63119-2951
Practice Address - Country:US
Practice Address - Phone:314-737-4070
Practice Address - Fax:314-737-4071
Is Sole Proprietor?:No
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007008838133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered