Provider Demographics
NPI:1518393586
Name:SECOSKY, KELLY RENEE (MFN, RD, LDN)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:RENEE
Last Name:SECOSKY
Suffix:
Gender:F
Credentials:MFN, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8380 SIX FORKS RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-5081
Mailing Address - Country:US
Mailing Address - Phone:919-896-8520
Mailing Address - Fax:
Practice Address - Street 1:8380 SIX FORKS RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-5081
Practice Address - Country:US
Practice Address - Phone:919-896-8520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-22
Last Update Date:2013-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL004131133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered