Provider Demographics
NPI:1689160566
Name:STAPLETON, KELLY (RD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:STAPLETON
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 1:6100 S PACIFIC COAST HWY APT 14
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-5957
Mailing Address - Country:US
Mailing Address - Phone:617-224-3923
Mailing Address - Fax:
Practice Address - Street 1:3630 E IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-2609
Practice Address - Country:US
Practice Address - Phone:310-900-7867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-03
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86018613133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric