Provider Demographics
NPI:1679828008
Name:DEVLIN, KELLEY E (RD)
Entity Type:Individual
Prefix:MS
First Name:KELLEY
Middle Name:E
Last Name:DEVLIN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:968 FAIRFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06605-1116
Mailing Address - Country:US
Mailing Address - Phone:203-330-6000
Mailing Address - Fax:203-382-9425
Practice Address - Street 1:968 FAIRFIELD AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06605-1116
Practice Address - Country:US
Practice Address - Phone:203-330-6000
Practice Address - Fax:203-382-9425
Is Sole Proprietor?:No
Enumeration Date:2012-07-23
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001113133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004236130Medicaid