Provider Demographics
NPI:1912122730
Name:KANE, KELLY ANN (MS, RD, LDN)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:ANN
Last Name:KANE
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:MRS
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, RD, LDN
Mailing Address - Street 1:79 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02861-1315
Mailing Address - Country:US
Mailing Address - Phone:617-640-4446
Mailing Address - Fax:617-636-8325
Practice Address - Street 1:750 WASHINGTON ST # 783
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1526
Practice Address - Country:US
Practice Address - Phone:617-636-8309
Practice Address - Fax:617-636-8325
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA786133V00000X
RILDN493133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAKA MT0556Medicare ID - Type UnspecifiedMEDICAL NUTRITION THERAPI