Provider Demographics
NPI:1104067073
Name:SCANLON, KELLY LYNN (CN (INTERN STUDENT))
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:LYNN
Last Name:SCANLON
Suffix:
Gender:F
Credentials:CN (INTERN STUDENT)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1344 BEAVERBROOK DR
Mailing Address - Street 2:
Mailing Address - City:HOLLY
Mailing Address - State:MI
Mailing Address - Zip Code:48442-8628
Mailing Address - Country:US
Mailing Address - Phone:248-634-3014
Mailing Address - Fax:
Practice Address - Street 1:1344 BEAVERBROOK DR
Practice Address - Street 2:
Practice Address - City:HOLLY
Practice Address - State:MI
Practice Address - Zip Code:48442-8628
Practice Address - Country:US
Practice Address - Phone:248-634-3014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-23
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist