Provider Demographics
NPI:1437343027
Name:LEBOLT, KELLY JO (MS, RD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JO
Last Name:LEBOLT
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 ELECTRIC RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-1621
Mailing Address - Country:US
Mailing Address - Phone:540-772-4930
Mailing Address - Fax:
Practice Address - Street 1:1910 ELECTRIC RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-1621
Practice Address - Country:US
Practice Address - Phone:540-772-4930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-28
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered