Provider Demographics
NPI:1750569539
Name:PENDLETON, KELLY (RD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:PENDLETON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:STEPHENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:209 KYLE CT
Mailing Address - Street 2:
Mailing Address - City:GARDENDALE
Mailing Address - State:AL
Mailing Address - Zip Code:35071-2716
Mailing Address - Country:US
Mailing Address - Phone:678-764-3940
Mailing Address - Fax:
Practice Address - Street 1:592 FIELDSTOWN RD
Practice Address - Street 2:STE. 102 - CKD SERVICES OF GARDENDALE
Practice Address - City:GARDENDALE
Practice Address - State:AL
Practice Address - Zip Code:35071-3414
Practice Address - Country:US
Practice Address - Phone:205-608-3653
Practice Address - Fax:205-608-3654
Is Sole Proprietor?:No
Enumeration Date:2008-02-05
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL945221133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal