Provider Demographics
NPI:1679699524
Name:RAETZSCH, KELLEY M (RD, CSSD)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:M
Last Name:RAETZSCH
Suffix:
Gender:F
Credentials:RD, CSSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3330 BOURBON ST
Mailing Address - Street 2:SUITE 128
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22408-7333
Mailing Address - Country:US
Mailing Address - Phone:540-847-7706
Mailing Address - Fax:
Practice Address - Street 1:3330 BOURBON ST
Practice Address - Street 2:SUITE 128
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22408-7333
Practice Address - Country:US
Practice Address - Phone:540-847-7706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered