Provider Demographics
NPI:1023615010
Name:GRESIAK, KELLEY (RD, CEDRD)
Entity type:Individual
Prefix:MRS
First Name:KELLEY
Middle Name:
Last Name:GRESIAK
Suffix:
Gender:F
Credentials:RD, CEDRD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3390 DARBY ST UNIT 330
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-5301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2660 TOWNSGATE RD STE 610
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-5709
Practice Address - Country:US
Practice Address - Phone:805-285-2719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-03
Last Update Date:2020-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered