Provider Demographics
NPI:1083910012
Name:KENNELLEY, KELLY MICHELLE (RD, LDN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MICHELLE
Last Name:KENNELLEY
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 BARBER PL
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16507-1863
Mailing Address - Country:US
Mailing Address - Phone:814-453-7661
Mailing Address - Fax:814-874-5505
Practice Address - Street 1:100 BARBER PL
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16507-1863
Practice Address - Country:US
Practice Address - Phone:814-453-7661
Practice Address - Fax:814-874-5505
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-09
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN002326133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered