Provider Demographics
NPI:1508385873
Name:KULL, KELLEY KAY
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:KAY
Last Name:KULL
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 1:12178 BOREHAM MINE RD
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-9322
Mailing Address - Country:US
Mailing Address - Phone:530-386-4098
Mailing Address - Fax:
Practice Address - Street 1:12178 BOREHAM MINE RD
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-9322
Practice Address - Country:US
Practice Address - Phone:530-386-4098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA727521133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1659361392Medicaid