Provider Demographics
NPI:1396578985
Name:DOUGLASS, KELLY ANA (RD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANA
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 777447
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89077-7447
Mailing Address - Country:US
Mailing Address - Phone:833-759-8720
Mailing Address - Fax:
Practice Address - Street 1:8480 S EASTERN AVE STE F
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89123-2822
Practice Address - Country:US
Practice Address - Phone:833-759-8720
Practice Address - Fax:833-486-3561
Is Sole Proprietor?:No
Enumeration Date:2024-08-21
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV40902-DI-0133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered