Basic Information
| Provider Information | |||||||||
| NPI: | 1356788400 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLEY | ||||||||
| FirstName: | BEVERLY | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RD,LD,CDE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1717B S UTICA AVE | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741045333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187442273 | ||||||||
| FaxNumber: | 9187442483 | ||||||||
| Practice Location | |||||||||
| Address1: | 1717B S UTICA AVE | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741045333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187442273 | ||||||||
| FaxNumber: | 9187442483 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2013 | ||||||||
| LastUpdateDate: | 05/30/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | LD472 | OK | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.