Provider Demographics
NPI:1922629385
Name:WILLS, KELLY (MS, RD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WILLS
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5955 CAPISTRANO AVE STE E
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93422-7227
Mailing Address - Country:US
Mailing Address - Phone:805-668-3404
Mailing Address - Fax:805-549-5066
Practice Address - Street 1:5955 CAPISTRANO AVE STE E
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-7227
Practice Address - Country:US
Practice Address - Phone:805-668-3404
Practice Address - Fax:805-549-5066
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-27
Last Update Date:2023-03-21
Deactivation Date:2020-04-27
Deactivation Code:
Reactivation Date:2020-07-01
Provider Licenses
StateLicense IDTaxonomies
CA86063722133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered