Provider Demographics
NPI:1750061057
Name:KELLY, GILLIAN
Entity type:Individual
Prefix:
First Name:GILLIAN
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2083 CHANNING DR UNIT 202
Mailing Address - Street 2:
Mailing Address - City:ROCKINGHAM
Mailing Address - State:VA
Mailing Address - Zip Code:22801-3077
Mailing Address - Country:US
Mailing Address - Phone:570-687-0711
Mailing Address - Fax:
Practice Address - Street 1:1310 24TH AVE S
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37212-2637
Practice Address - Country:US
Practice Address - Phone:570-687-0711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-20
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered