Provider Demographics
NPI:1790983815
Name:KICHLER, KELLEY GRANADE (RD, LD, CNSD)
Entity Type:Individual
Prefix:MRS
First Name:KELLEY
Middle Name:GRANADE
Last Name:KICHLER
Suffix:
Gender:F
Credentials:RD, LD, CNSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:CORDELE
Mailing Address - State:GA
Mailing Address - Zip Code:31015-3234
Mailing Address - Country:US
Mailing Address - Phone:229-276-3375
Mailing Address - Fax:
Practice Address - Street 1:902 N 7TH ST
Practice Address - Street 2:
Practice Address - City:CORDELE
Practice Address - State:GA
Practice Address - Zip Code:31015-3234
Practice Address - Country:US
Practice Address - Phone:229-276-3375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD002541133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered