Provider Demographics
NPI:1588751051
Name:KELLY, MARGARET JUANITA (MS, RD)
Entity type:Individual
Prefix:MS
First Name:MARGARET
Middle Name:JUANITA
Last Name:KELLY
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5974 PENTZ RD
Mailing Address - Street 2:
Mailing Address - City:PARADISE
Mailing Address - State:CA
Mailing Address - Zip Code:95969-5509
Mailing Address - Country:US
Mailing Address - Phone:530-877-9361
Mailing Address - Fax:530-876-7943
Practice Address - Street 1:5974 PENTZ RD
Practice Address - Street 2:
Practice Address - City:PARADISE
Practice Address - State:CA
Practice Address - Zip Code:95969-5509
Practice Address - Country:US
Practice Address - Phone:530-877-9361
Practice Address - Fax:530-876-7943
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA884510133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ266312Medicare ID - Type UnspecifiedREGISTERED DIETITIAN