Provider Demographics
NPI:1073944369
Name:BRENNAN, KELLY ELIZABETH (MS, RD, LD)
Entity Type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:ELIZABETH
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:MS, 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:PO BOX 6069
Mailing Address - Street 2:
Mailing Address - City:INCLINE VILLAGE
Mailing Address - State:NV
Mailing Address - Zip Code:89450-6069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:837 SOUTHWOOD BLVD
Practice Address - Street 2:
Practice Address - City:INCLINE VILLAGE
Practice Address - State:NV
Practice Address - Zip Code:89451-7434
Practice Address - Country:US
Practice Address - Phone:908-672-7784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-11
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV34003DI-0133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered