Provider Demographics
NPI:1588268429
Name:WILSON, KELLY (MS, RD, LD, CSO)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS, RD, LD, CSO
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD
Mailing Address - Street 1:1242 DEMARET LN
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77055-6136
Mailing Address - Country:US
Mailing Address - Phone:254-493-5962
Mailing Address - Fax:
Practice Address - Street 1:1242 DEMARET LN
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77055-6136
Practice Address - Country:US
Practice Address - Phone:254-493-5962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-22
Last Update Date:2020-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133VN1301X
TX86041805133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1301XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Oncology