Provider Demographics
NPI:1962677252
Name:PANEITZ, KELLY D (RD, LD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:D
Last Name:PANEITZ
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:751 SAPPINGTON BRIDGE RD
Mailing Address - Street 2:MISSOURI BAPTIST HOSPITAL - SULLIVAN
Mailing Address - City:SULLIVAN
Mailing Address - State:MO
Mailing Address - Zip Code:63080-2354
Mailing Address - Country:US
Mailing Address - Phone:573-468-1347
Mailing Address - Fax:573-468-1125
Practice Address - Street 1:751 SAPPINGTON BRIDGE RD
Practice Address - Street 2:MISSOURI BAPTIST HOSPITAL - SULLIVAN
Practice Address - City:SULLIVAN
Practice Address - State:MO
Practice Address - Zip Code:63080-2354
Practice Address - Country:US
Practice Address - Phone:573-468-1347
Practice Address - Fax:573-468-1125
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-28
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001012812133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered