Provider Demographics
NPI:1750038865
Name:KELLY, SANDRA LYNN (DTR)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:LYNN
Last Name:KELLY
Suffix:
Gender:F
Credentials:DTR
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:262 DANNY THOMAS PL
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38105-3678
Mailing Address - Country:US
Mailing Address - Phone:901-595-0499
Mailing Address - Fax:901-595-3202
Practice Address - Street 1:262 DANNY THOMAS PL
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38105-3678
Practice Address - Country:US
Practice Address - Phone:901-595-0499
Practice Address - Fax:901-595-3202
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-08
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN975125136A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered