Provider Demographics
NPI:1205232634
Name:KELLY, AUTUMN ROSE (RD, LD)
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:ROSE
Last Name:KELLY
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 1:23767 667TH AVE
Mailing Address - Street 2:
Mailing Address - City:NEVADA
Mailing Address - State:IA
Mailing Address - Zip Code:50201-7616
Mailing Address - Country:US
Mailing Address - Phone:319-480-5574
Mailing Address - Fax:
Practice Address - Street 1:3 S 4TH AVE
Practice Address - Street 2:FOOD AND NUTRITION SERVICES
Practice Address - City:MARSHALLTOWN
Practice Address - State:IA
Practice Address - Zip Code:50158-2924
Practice Address - Country:US
Practice Address - Phone:641-754-5271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-12
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002148133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered