Provider Demographics
NPI:1902085459
Name:BAILEY, KELLY RENEA (RD, LD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:RENEA
Last Name:BAILEY
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:RENEA
Other - Last Name:CONNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:1105 E VINE ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050-3658
Mailing Address - Country:US
Mailing Address - Phone:740-507-4858
Mailing Address - Fax:
Practice Address - Street 1:1330 COSHOCTON AVE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-1440
Practice Address - Country:US
Practice Address - Phone:740-393-9147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-01
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6036133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered