Provider Demographics
NPI:1518187772
Name:KELLY, MARY ANN (RD)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ANN
Last Name:KELLY
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:PO BOX 1357
Mailing Address - Street 2:
Mailing Address - City:JOSHUA TREE
Mailing Address - State:CA
Mailing Address - Zip Code:92252-0839
Mailing Address - Country:US
Mailing Address - Phone:760-954-1308
Mailing Address - Fax:760-418-2243
Practice Address - Street 1:6448 HALLEE RD STE 9
Practice Address - Street 2:
Practice Address - City:JOSHUA TREE
Practice Address - State:CA
Practice Address - Zip Code:92252-1908
Practice Address - Country:US
Practice Address - Phone:760-366-8390
Practice Address - Fax:760-418-2243
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-27
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL709057132700000X, 133N00000X, 133V00000X, 133VN1004X, 133VN1005X, 133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No132700000XDietary & Nutritional Service ProvidersDietary Manager
No133N00000XDietary & Nutritional Service ProvidersNutritionist
Not Answered133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
Not Answered133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
Not Answered133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic