Provider Demographics
NPI:1558952648
Name:TALIAFERRO, KELLY MARIE (RDN, LD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:TALIAFERRO
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:THORNTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6139 AMBLE TRL
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78249-2108
Mailing Address - Country:US
Mailing Address - Phone:940-367-0613
Mailing Address - Fax:
Practice Address - Street 1:6139 AMBLE TRL
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78249-2108
Practice Address - Country:US
Practice Address - Phone:210-504-6434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-01
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT82599133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered