Provider Demographics
NPI:1114517448
Name:NICHOLSON, KELSEY SCOT
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:SCOT
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13407 15TH ST
Mailing Address - Street 2:
Mailing Address - City:GRANDVIEW
Mailing Address - State:MO
Mailing Address - Zip Code:64030-3026
Mailing Address - Country:US
Mailing Address - Phone:913-609-9900
Mailing Address - Fax:
Practice Address - Street 1:13407 15TH ST
Practice Address - Street 2:
Practice Address - City:GRANDVIEW
Practice Address - State:MO
Practice Address - Zip Code:64030-3026
Practice Address - Country:US
Practice Address - Phone:913-609-9900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered