Provider Demographics
NPI:1265982748
Name:TRIPP, KELSEY
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:TRIPP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 THAMES CIR
Mailing Address - Street 2:
Mailing Address - City:NICHOLASVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40356-9219
Mailing Address - Country:US
Mailing Address - Phone:540-589-4613
Mailing Address - Fax:
Practice Address - Street 1:512 THAMES CIR
Practice Address - Street 2:
Practice Address - City:NICHOLASVILLE
Practice Address - State:KY
Practice Address - Zip Code:40356-9219
Practice Address - Country:US
Practice Address - Phone:540-589-4613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-10
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY86043609133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered