Provider Demographics
NPI:1912477019
Name:MCCULLOUGH, KELSEY (RD, LD)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 VT ROUTE 5A
Mailing Address - Street 2:
Mailing Address - City:WEST BURKE
Mailing Address - State:VT
Mailing Address - Zip Code:05871-4415
Mailing Address - Country:US
Mailing Address - Phone:603-991-7996
Mailing Address - Fax:
Practice Address - Street 1:67 VT ROUTE 5A
Practice Address - Street 2:
Practice Address - City:WEST BURKE
Practice Address - State:VT
Practice Address - Zip Code:05871-4415
Practice Address - Country:US
Practice Address - Phone:603-991-7996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-30
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0825133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered