Provider Demographics
NPI:1992273346
Name:DEMERS, KELLY ANN (RD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:DEMERS
Suffix:
Gender:
Credentials:RD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD
Mailing Address - Street 1:17 OAK ST APT 5
Mailing Address - Street 2:
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05301-6715
Mailing Address - Country:US
Mailing Address - Phone:518-545-0128
Mailing Address - Fax:
Practice Address - Street 1:10600 S PENNSYLVANIA AVE STE 16
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73170-4257
Practice Address - Country:US
Practice Address - Phone:405-960-3120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-04
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4433133V00000X
ORD-10195067133V00000X
VT0740134470133V00000X
OK3084133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered