Provider Demographics
NPI:1770250045
Name:MYERS, KELLY (RDN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MYERS
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9613 WATERGATE RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28270-2107
Mailing Address - Country:US
Mailing Address - Phone:321-704-9391
Mailing Address - Fax:
Practice Address - Street 1:428 E 4TH ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28202-2434
Practice Address - Country:US
Practice Address - Phone:704-380-4655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-25
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL006474133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered