Provider Demographics
NPI:1245562651
Name:KELLY, MELISSA (MS, RD, CDN)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:MS, RD, CDN
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:BUCZEK-KELLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, RD, CDN
Mailing Address - Street 1:50 FERNDALE AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN ROCK
Mailing Address - State:NJ
Mailing Address - Zip Code:07452-2704
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:51 NEWARK ST
Practice Address - Street 2:SUITE 404A
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030-4548
Practice Address - Country:US
Practice Address - Phone:646-303-5567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-10
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY930037133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered