Provider Demographics
NPI:1104222652
Name:SCOTT, KELLY L (RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:L
Last Name:SCOTT
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 1:1755 ISLAND DR
Mailing Address - Street 2:
Mailing Address - City:POLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44514-5603
Mailing Address - Country:US
Mailing Address - Phone:330-550-3655
Mailing Address - Fax:888-482-5741
Practice Address - Street 1:819 SOUTHWESTERN RUN
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44514-3688
Practice Address - Country:US
Practice Address - Phone:330-629-9991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-11
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD.6119133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH47-2386782OtherEIN