Provider Demographics
NPI:1639470354
Name:BAKES, KELLY ANN (RD, LDN)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANN
Last Name:BAKES
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:STROGEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:175 STRAFFORD AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:PA
Mailing Address - Zip Code:19087-3340
Mailing Address - Country:US
Mailing Address - Phone:484-253-1082
Mailing Address - Fax:
Practice Address - Street 1:175 STRAFFORD AVE STE 1
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:PA
Practice Address - Zip Code:19087-3340
Practice Address - Country:US
Practice Address - Phone:484-253-1082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-11
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN004453133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered