Provider Demographics
NPI:1326877192
Name:FORMAN, KELLY ANN (RDN)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:ANN
Last Name:FORMAN
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:WETMORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:41 SIMSBURY LNDG
Mailing Address - Street 2:
Mailing Address - City:SIMSBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06070-1436
Mailing Address - Country:US
Mailing Address - Phone:203-216-9932
Mailing Address - Fax:
Practice Address - Street 1:41 SIMSBURY LNDG
Practice Address - Street 2:
Practice Address - City:SIMSBURY
Practice Address - State:CT
Practice Address - Zip Code:06070-1436
Practice Address - Country:US
Practice Address - Phone:203-216-9932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-30
Last Update Date:2025-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered