Provider Demographics
NPI:1619221041
Name:MALONE, KELLY RYAN (MA, RD, LDN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:RYAN
Last Name:MALONE
Suffix:
Gender:F
Credentials:MA, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 MARTIN BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:LEICESTER
Mailing Address - State:NC
Mailing Address - Zip Code:28748-6302
Mailing Address - Country:US
Mailing Address - Phone:828-206-0715
Mailing Address - Fax:
Practice Address - Street 1:207 MARTIN BRANCH RD
Practice Address - Street 2:
Practice Address - City:LEICESTER
Practice Address - State:NC
Practice Address - Zip Code:28748-6302
Practice Address - Country:US
Practice Address - Phone:828-206-0715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-07
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC979040133NN1002X, 133V00000X, 133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic