Provider Demographics
NPI:1215410790
Name:KELLY, MARY JANE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:KELLY
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 1:1046 E ELGENIA AVE
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-1318
Mailing Address - Country:US
Mailing Address - Phone:626-862-5686
Mailing Address - Fax:
Practice Address - Street 1:1046 E ELGENIA AVE
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-1318
Practice Address - Country:US
Practice Address - Phone:626-862-5686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-11
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered