Provider Demographics
NPI:1760901045
Name:KELLY, KRISTEN (RD)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:KELLY
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 1:2720 S ARLINGTON MILL DR UNIT 304
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22206-3404
Mailing Address - Country:US
Mailing Address - Phone:240-506-6483
Mailing Address - Fax:
Practice Address - Street 1:1501 LEE HWY STE 130
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22209-1109
Practice Address - Country:US
Practice Address - Phone:240-506-6483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-18
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
965850133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered