Provider Demographics
NPI:1568834166
Name:KELLY, SARA (RD, LD)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 W CIRCLE DR NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901
Mailing Address - Country:US
Mailing Address - Phone:507-292-6000
Mailing Address - Fax:
Practice Address - Street 1:4200 W CIRCLE DR NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901
Practice Address - Country:US
Practice Address - Phone:507-292-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-22
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLD 3557133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered