Provider Demographics
NPI:1629106976
Name:KELLY, DORIS ANN (MS, RD, CD)
Entity Type:Individual
Prefix:MRS
First Name:DORIS
Middle Name:ANN
Last Name:KELLY
Suffix:
Gender:F
Credentials:MS, 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:PO BOX 635
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-0635
Mailing Address - Country:US
Mailing Address - Phone:509-943-0414
Mailing Address - Fax:
Practice Address - Street 1:719 JADWIN AVE
Practice Address - Street 2:SUITE 7
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-4217
Practice Address - Country:US
Practice Address - Phone:509-943-0414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00000116133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB36369Medicare ID - Type Unspecified