Provider Demographics
NPI:1528535325
Name:BREYER, KELLEY (RD)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:BREYER
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 1:164 RIDGELAND CIR
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-2163
Mailing Address - Country:US
Mailing Address - Phone:203-631-4228
Mailing Address - Fax:
Practice Address - Street 1:11 GRIEB TRL
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-2655
Practice Address - Country:US
Practice Address - Phone:860-884-9718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001406133V00000X
CT001273133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered