Provider Demographics
NPI:1952189144
Name:HASKINS, KELLIE BROOKE (RD)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:BROOKE
Last Name:HASKINS
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 1:176 BROAD ST APT 411
Mailing Address - Street 2:
Mailing Address - City:DALEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24083-1176
Mailing Address - Country:US
Mailing Address - Phone:540-354-1998
Mailing Address - Fax:
Practice Address - Street 1:3 RIVERSIDE CIR
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-4955
Practice Address - Country:US
Practice Address - Phone:540-224-5170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-19
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86155963133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered