Provider Demographics
NPI:1356788400
Name:KELLEY, BEVERLY KAY (RD,LD,CDE)
Entity type:Individual
Prefix:MS
First Name:BEVERLY
Middle Name:KAY
Last Name:KELLEY
Suffix:
Gender:F
Credentials:RD,LD,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717B S UTICA AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5333
Mailing Address - Country:US
Mailing Address - Phone:918-744-2273
Mailing Address - Fax:918-744-2483
Practice Address - Street 1:1717B S UTICA AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5333
Practice Address - Country:US
Practice Address - Phone:918-744-2273
Practice Address - Fax:918-744-2483
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-30
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKLD472133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered