Provider Demographics
NPI:1770527996
Name:LEWIS, KELLY MARIE (RD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PALMETTO HEALTH
Mailing Address - Street 2:1321 LADY STREET 1ST FLOOR
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201
Mailing Address - Country:US
Mailing Address - Phone:803-296-2548
Mailing Address - Fax:803-296-2525
Practice Address - Street 1:PALMETTO HEALTH RICHLAND
Practice Address - Street 2:3301 HARDEN STREET 5 MEDICAL PARK
Practice Address - City:COULMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203
Practice Address - Country:US
Practice Address - Phone:803-296-2548
Practice Address - Fax:803-296-2525
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC809431133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ32883Medicare UPIN