Provider Demographics
NPI:1548695687
Name:GEMMEL, KELLY LYNN (RDN, CLT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:GEMMEL
Suffix:
Gender:F
Credentials:RDN, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4660 S HAGADORN RD
Mailing Address - Street 2:SUITE 280E
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-5376
Mailing Address - Country:US
Mailing Address - Phone:517-574-5863
Mailing Address - Fax:517-574-5958
Practice Address - Street 1:4660 S HAGADORN RD
Practice Address - Street 2:SUITE 280E
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-5376
Practice Address - Country:US
Practice Address - Phone:517-574-5863
Practice Address - Fax:517-574-5958
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-09
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered