Provider Demographics
NPI:1578185674
Name:BARNES, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BARNES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11705 LOISDALE WAY
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95742-8028
Mailing Address - Country:US
Mailing Address - Phone:916-208-0552
Mailing Address - Fax:
Practice Address - Street 1:11705 LOISDALE WAY
Practice Address - Street 2:
Practice Address - City:RANCHO CORDOVA
Practice Address - State:CA
Practice Address - Zip Code:95742-8028
Practice Address - Country:US
Practice Address - Phone:916-208-0552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-12
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA931140133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered