Basic Information
| Provider Information | |||||||||
| NPI: | 1073941688 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | MARJORIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | R.D., L.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 231 W LOCKWOOD AVE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | WEBSTER GROVES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631192951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3147374070 | ||||||||
| FaxNumber: | 3147374071 | ||||||||
| Practice Location | |||||||||
| Address1: | 231 W LOCKWOOD AVE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | WEBSTER GROVES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631192951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3147374070 | ||||||||
| FaxNumber: | 3147374071 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2013 | ||||||||
| LastUpdateDate: | 10/16/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 2007008838 | MO | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.