Provider Demographics
NPI:1386200855
Name:FONTES, KELLY ELIZABETH (RDN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ELIZABETH
Last Name:FONTES
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8115 BENNINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:WHITE LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48386-3564
Mailing Address - Country:US
Mailing Address - Phone:989-992-6465
Mailing Address - Fax:
Practice Address - Street 1:8115 BENNINGTON BLVD
Practice Address - Street 2:
Practice Address - City:WHITE LAKE
Practice Address - State:MI
Practice Address - Zip Code:48386-3564
Practice Address - Country:US
Practice Address - Phone:989-992-6465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-10
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered