Provider Demographics
NPI:1881083988
Name:KELLEY, MARY CLARE (RDN)
Entity type:Individual
Prefix:
First Name:MARY CLARE
Middle Name:
Last Name:KELLEY
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:PO BOX 996
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-0996
Mailing Address - Country:US
Mailing Address - Phone:208-664-4026
Mailing Address - Fax:855-532-5921
Practice Address - Street 1:6001 N MAYFAIR ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-1129
Practice Address - Country:US
Practice Address - Phone:509-462-2273
Practice Address - Fax:509-462-2275
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-13
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA86009851136A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered