Provider Demographics
NPI:1376777375
Name:KELLY, KATHRYN (MS, LDN, RD, CDE)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:MS, LDN, RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 SAMUEL WOODWORTH RD
Mailing Address - Street 2:
Mailing Address - City:NORWELL
Mailing Address - State:MA
Mailing Address - Zip Code:02061-1322
Mailing Address - Country:US
Mailing Address - Phone:781-424-8382
Mailing Address - Fax:
Practice Address - Street 1:1221 MAIN ST
Practice Address - Street 2:SUITE 203
Practice Address - City:SOUTH WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190-1561
Practice Address - Country:US
Practice Address - Phone:781-335-7559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-06
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA404133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered