Provider Demographics
NPI:1083832844
Name:BALLEK, KERRY LYNN (RD)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:LYNN
Last Name:BALLEK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:KERRY
Other - Middle Name:LYNN
Other - Last Name:LANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:1626 FREELAND RD
Mailing Address - Street 2:
Mailing Address - City:FREELAND
Mailing Address - State:MD
Mailing Address - Zip Code:21053-9577
Mailing Address - Country:US
Mailing Address - Phone:410-343-1484
Mailing Address - Fax:
Practice Address - Street 1:1626 FREELAND RD
Practice Address - Street 2:
Practice Address - City:FREELAND
Practice Address - State:MD
Practice Address - Zip Code:21053-9577
Practice Address - Country:US
Practice Address - Phone:410-343-1484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD01493133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD932RMedicare ID - Type UnspecifiedREGISTERED DIETITIAN