Provider Demographics
NPI:1144600115
Name:KELLY, KIMBERLY ANN (ND, RD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:KELLY
Suffix:
Gender:F
Credentials:ND, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22287 MULHOLLAND HWY # 669
Mailing Address - Street 2:
Mailing Address - City:CALABASAS
Mailing Address - State:CA
Mailing Address - Zip Code:91302-5157
Mailing Address - Country:US
Mailing Address - Phone:747-263-9451
Mailing Address - Fax:
Practice Address - Street 1:8920 WILSHIRE BLVD STE 610
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-2006
Practice Address - Country:US
Practice Address - Phone:424-389-9451
Practice Address - Fax:833-551-4828
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-04
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1106458133V00000X
CAND1328175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered