Provider Demographics
NPI:1275231433
Name:TAHLOR, KELLY DANIELLE (RDN, CDN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:DANIELLE
Last Name:TAHLOR
Suffix:
Gender:F
Credentials:RDN, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 S HOWELL AVE STE D
Mailing Address - Street 2:
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720-4445
Mailing Address - Country:US
Mailing Address - Phone:631-444-2274
Mailing Address - Fax:
Practice Address - Street 1:23 S HOWELL AVE STE D
Practice Address - Street 2:
Practice Address - City:CENTEREACH
Practice Address - State:NY
Practice Address - Zip Code:11720-4445
Practice Address - Country:US
Practice Address - Phone:631-444-2274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-17
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011259133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY011259OtherDIETETICS-NUTRITION (048)