Provider Demographics
NPI:1417645540
Name:WEIDLE, KELLY ANN (RD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:WEIDLE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4735 OGLETOWN STANTON RD STE 1211
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-2089
Mailing Address - Country:US
Mailing Address - Phone:302-623-3052
Mailing Address - Fax:
Practice Address - Street 1:4735 OGLETOWN STANTON RD STE 1211
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2089
Practice Address - Country:US
Practice Address - Phone:302-623-3052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-26
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered