Provider Demographics
NPI:1669283297
Name:GREBNER, KELLY CAMPBELL (RD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:CAMPBELL
Last Name:GREBNER
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 1:3074 GIBRALTAR BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-2440
Mailing Address - Country:US
Mailing Address - Phone:732-456-1393
Mailing Address - Fax:
Practice Address - Street 1:3074 GIBRALTAR BLVD
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-2440
Practice Address - Country:US
Practice Address - Phone:732-456-1393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-14
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL86302700133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered