Provider Demographics
NPI:1376026591
Name:ECKERT, KELLY ANNE
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:ECKERT
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 1:93 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13903-1645
Mailing Address - Country:US
Mailing Address - Phone:607-763-6092
Mailing Address - Fax:
Practice Address - Street 1:93 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13903-1645
Practice Address - Country:US
Practice Address - Phone:607-763-6092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-13
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011166133V00000X
PA7705133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered