Provider Demographics
NPI:1629194915
Name:GAFNI, KELLY MARIE (RD)
Entity Type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:MARIE
Last Name:GAFNI
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:MARIE
Other - Last Name:CHARBONEAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 54679
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90054-0679
Mailing Address - Country:US
Mailing Address - Phone:310-577-5540
Mailing Address - Fax:
Practice Address - Street 1:4640 ADMIRALTY WAY STE 901
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6621
Practice Address - Country:US
Practice Address - Phone:310-577-5540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA940452133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered