Provider Demographics
NPI:1861882557
Name:KELLEY, KATHLEEN HELEN (RD, LDN)
Entity type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:HELEN
Last Name:KELLEY
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 VAN BUREN RD
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-5323
Mailing Address - Country:US
Mailing Address - Phone:860-463-9655
Mailing Address - Fax:860-763-1260
Practice Address - Street 1:15 PALOMBA DR
Practice Address - Street 2:2
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-3888
Practice Address - Country:US
Practice Address - Phone:860-253-9950
Practice Address - Fax:860-253-9398
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3511133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered