Provider Demographics
NPI:1225879380
Name:GLENNON, KELLY (RD, LDN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GLENNON
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 1:120 MCCOOL BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19380-2811
Mailing Address - Country:US
Mailing Address - Phone:484-844-4465
Mailing Address - Fax:
Practice Address - Street 1:3724 JEFFERSON ST STE 104
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-6204
Practice Address - Country:US
Practice Address - Phone:512-692-7045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-03
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN008189133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered