Provider Demographics
NPI:1588664387
Name:ANDERSON, KELLI (LDN)
Entity Type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 GREEVES ST
Mailing Address - Street 2:
Mailing Address - City:KANE
Mailing Address - State:PA
Mailing Address - Zip Code:16735-1522
Mailing Address - Country:US
Mailing Address - Phone:814-837-8513
Mailing Address - Fax:
Practice Address - Street 1:116 INTERSTATE PKWY
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:PA
Practice Address - Zip Code:16701-1036
Practice Address - Country:US
Practice Address - Phone:814-368-4143
Practice Address - Fax:814-362-8708
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN001025133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA058480QNCMedicare ID - Type UnspecifiedDIETARY PROVIDER NUMBER