Provider Demographics
NPI:1548560667
Name:NUCKOLLS, KELLY LYNNETTE (MS RD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNNETTE
Last Name:NUCKOLLS
Suffix:
Gender:F
Credentials:MS RD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:LYNETTE
Other - Last Name:MASSA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:600 HIGHLAND AVE
Mailing Address - Street 2:MC 2433
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53792-1530
Mailing Address - Country:US
Mailing Address - Phone:608-662-0817
Mailing Address - Fax:
Practice Address - Street 1:600 HIGHLAND AVE
Practice Address - Street 2:MC 2433
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53792-1530
Practice Address - Country:US
Practice Address - Phone:608-662-0817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-22
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI976210133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2219-29OtherCERTIFIED DIETITIAN