Provider Demographics
NPI:1114341708
Name:TILLER, KELSEY (RD, LD)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:TILLER
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 1:100 ROBERTS RD
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29440-6898
Mailing Address - Country:US
Mailing Address - Phone:843-485-2234
Mailing Address - Fax:
Practice Address - Street 1:100 ROBERTS RD
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440-6898
Practice Address - Country:US
Practice Address - Phone:843-485-2234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-18
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1135133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered