Provider Demographics
NPI:1336651645
Name:SCOTT, KELLY (MS, RDN, LD)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:
Last Name:SCOTT
Suffix:
Gender:F
Credentials:MS, RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:827 HAYMARKET PL
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-6972
Mailing Address - Country:US
Mailing Address - Phone:631-252-5929
Mailing Address - Fax:
Practice Address - Street 1:827 HAYMARKET PL
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-6972
Practice Address - Country:US
Practice Address - Phone:631-252-5929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-26
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1652133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered