Provider Demographics
NPI:1932120821
Name:KELLY, MARY ELLEN (MS, RD, CDN)
Entity type:Individual
Prefix:MISS
First Name:MARY
Middle Name:ELLEN
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 1:55 HUNTINGTON RD
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:MA
Mailing Address - Zip Code:02186-5311
Mailing Address - Country:US
Mailing Address - Phone:617-784-3678
Mailing Address - Fax:
Practice Address - Street 1:55 HUNTINGTON RD
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:MA
Practice Address - Zip Code:02186-5311
Practice Address - Country:US
Practice Address - Phone:617-784-3678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00952137133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered