Provider Demographics
NPI:1285666453
Name:DICK, KELLY M (RD, LD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:DICK
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25193 BEEHIVE CT
Mailing Address - Street 2:
Mailing Address - City:WEST HARRISON
Mailing Address - State:IN
Mailing Address - Zip Code:47060-6643
Mailing Address - Country:US
Mailing Address - Phone:812-637-0531
Mailing Address - Fax:
Practice Address - Street 1:3200 VINE ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45220-2213
Practice Address - Country:US
Practice Address - Phone:513-861-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
913232133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered