Provider Demographics
NPI:1255953048
Name:ARBUCKLE, KELLY S (RD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:S
Last Name:ARBUCKLE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:S
Other - Last Name:WILLEFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:100 BRISTOL CT
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-1601
Mailing Address - Country:US
Mailing Address - Phone:815-823-7083
Mailing Address - Fax:
Practice Address - Street 1:5165 MCCARTY LN
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-8764
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-14
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37002899A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered