Provider Demographics
NPI:1588009443
Name:DREW, KELLY (RD, CD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:DREW
Suffix:
Gender:F
Credentials:RD, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:736 S 105TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-2542
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:736 S 105TH ST
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53214-2542
Practice Address - Country:US
Practice Address - Phone:262-853-0509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-06
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2342-029133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered