Provider Demographics
NPI:1902970254
Name:O'NEIL, KELLI J (MS, RD, LD, CDE)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:J
Last Name:O'NEIL
Suffix:
Gender:F
Credentials:MS, RD, LD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1475 HOLCOMB BRIDGE RD
Mailing Address - Street 2:SUITE 129
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-2139
Mailing Address - Country:US
Mailing Address - Phone:678-325-2250
Mailing Address - Fax:678-325-2261
Practice Address - Street 1:1475 HOLCOMB BRIDGE RD
Practice Address - Street 2:SUITE 129
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-2139
Practice Address - Country:US
Practice Address - Phone:678-325-2250
Practice Address - Fax:678-325-2261
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD002749133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered