Provider Demographics
NPI:1740646322
Name:HAWTHORNE, KELLY (RD, LD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:HAWTHORNE
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4008 DEER CREEK RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-1578
Mailing Address - Country:US
Mailing Address - Phone:502-594-0378
Mailing Address - Fax:
Practice Address - Street 1:3801 SPRINGHURST BLVD
Practice Address - Street 2:STE 104
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-6137
Practice Address - Country:US
Practice Address - Phone:502-594-0378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-12
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYBDNDTN00221280133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered