Provider Demographics
NPI:1750110714
Name:FISHER, KELLY POTYSMAN (DCN, RD, LD, FNAP)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:POTYSMAN
Last Name:FISHER
Suffix:
Gender:F
Credentials:DCN, RD, LD, FNAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 GREENLEAF DR
Mailing Address - Street 2:
Mailing Address - City:ALEDO
Mailing Address - State:TX
Mailing Address - Zip Code:76008-2840
Mailing Address - Country:US
Mailing Address - Phone:817-846-3104
Mailing Address - Fax:
Practice Address - Street 1:1304 GREENLEAF DR
Practice Address - Street 2:
Practice Address - City:ALEDO
Practice Address - State:TX
Practice Address - Zip Code:76008-2840
Practice Address - Country:US
Practice Address - Phone:817-846-3104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT81572133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered