Provider Demographics
NPI:1336260835
Name:DORFMAN, KELLY (MS, LND)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:DORFMAN
Suffix:
Gender:F
Credentials:MS, LND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10828 TUCKAHOE WAY
Mailing Address - Street 2:
Mailing Address - City:NORTH POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20878-4203
Mailing Address - Country:US
Mailing Address - Phone:301-340-2239
Mailing Address - Fax:301-340-6499
Practice Address - Street 1:10828 TUCKAHOE WAY
Practice Address - Street 2:
Practice Address - City:NORTH POTOMAC
Practice Address - State:MD
Practice Address - Zip Code:20878-4203
Practice Address - Country:US
Practice Address - Phone:301-340-2239
Practice Address - Fax:301-340-6499
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDB00221133N00000X
DCNU3133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist