Provider Demographics
NPI:1881373686
Name:MULLEN, KELLY (RD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MULLEN
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 1:18151 NE 31ST CT APT 1503
Mailing Address - Street 2:
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33160-2664
Mailing Address - Country:US
Mailing Address - Phone:929-270-9065
Mailing Address - Fax:
Practice Address - Street 1:18151 NE 31ST CT APT 1503
Practice Address - Street 2:
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33160-2664
Practice Address - Country:US
Practice Address - Phone:929-270-9065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-18
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND12289133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered