Provider Demographics
NPI:1669185542
Name:LANE, KELLY KATHARINA (MS, RD, LD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:KATHARINA
Last Name:LANE
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 POLARIS PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43082-8213
Mailing Address - Country:US
Mailing Address - Phone:614-797-0547
Mailing Address - Fax:
Practice Address - Street 1:460 POLARIS PKWY STE 200
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082-8213
Practice Address - Country:US
Practice Address - Phone:740-845-7327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-05
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD.10019133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered