Provider Demographics
NPI:1194014555
Name:KELLY, VICTORIA E (RD, CDN)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:E
Last Name:KELLY
Suffix:
Gender:F
Credentials:RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 TWIN PONDS DR
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-6432
Mailing Address - Country:US
Mailing Address - Phone:914-204-0018
Mailing Address - Fax:
Practice Address - Street 1:65 TWIN PONDS DR
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-6432
Practice Address - Country:US
Practice Address - Phone:914-204-0018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-06
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY859256133V00000X
NY6057-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered