Provider Demographics
NPI:1821312224
Name:GRAY, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 158
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40962-0158
Mailing Address - Country:US
Mailing Address - Phone:606-598-5564
Mailing Address - Fax:606-598-6615
Practice Address - Street 1:330 SHAMROCK RD
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40962-9201
Practice Address - Country:US
Practice Address - Phone:606-598-2425
Practice Address - Fax:606-598-4448
Is Sole Proprietor?:No
Enumeration Date:2010-03-15
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYKY-2130OtherR.D.