Provider Demographics
NPI:1205103520
Name:DICKSON, KELLY L (RD, LDN)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:L
Last Name:DICKSON
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:L
Other - Last Name:MARSTELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LDN
Mailing Address - Street 1:3421 CONCORD RD
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-9001
Mailing Address - Country:US
Mailing Address - Phone:717-851-7575
Mailing Address - Fax:717-812-5154
Practice Address - Street 1:25 MONUMENT RD STE 105
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-5049
Practice Address - Country:US
Practice Address - Phone:717-851-7575
Practice Address - Fax:717-812-5154
Is Sole Proprietor?:No
Enumeration Date:2011-12-01
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN004679133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
DN004679OtherLICENSE NUMBER
PA213935Medicare PIN