Provider Demographics
NPI:1356915227
Name:KELLY, KATHERINE GRACE (RDN, CDN)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:GRACE
Last Name:KELLY
Suffix:
Gender:F
Credentials:RDN, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 W 57TH ST STE 1207
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-2400
Mailing Address - Country:US
Mailing Address - Phone:212-333-4243
Mailing Address - Fax:
Practice Address - Street 1:119 W 57TH ST STE 1207
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-2400
Practice Address - Country:US
Practice Address - Phone:212-333-4243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-16
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY86074559133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered