Provider Demographics
NPI:1588987416
Name:KELLY, ALYSSA JENNIFER (MS, RD, CDN)
Entity type:Individual
Prefix:MRS
First Name:ALYSSA
Middle Name:JENNIFER
Last Name:KELLY
Suffix:
Gender:F
Credentials:MS, RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORT JERVIS
Mailing Address - State:NY
Mailing Address - Zip Code:12771-2253
Mailing Address - Country:US
Mailing Address - Phone:845-858-7023
Mailing Address - Fax:
Practice Address - Street 1:160 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PORT JERVIS
Practice Address - State:NY
Practice Address - Zip Code:12771-2253
Practice Address - Country:US
Practice Address - Phone:845-858-7023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-06
Last Update Date:2010-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY889231133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered