Provider Demographics
NPI:1568985356
Name:MAY, KELLIE BUCKLEY (RD)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:BUCKLEY
Last Name:MAY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:BUCKLEY
Other - Last Name:MAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:40702 COUNTY ROAD 26
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-6912
Mailing Address - Country:US
Mailing Address - Phone:308-765-0997
Mailing Address - Fax:
Practice Address - Street 1:3102 AVENUE D
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4300
Practice Address - Country:US
Practice Address - Phone:308-632-6236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-24
Last Update Date:2017-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE640373133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered