Basic Information
| Provider Information | |||||||||
| NPI: | 1588664387 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | KELLI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 630 GREEVES ST | ||||||||
| Address2: | |||||||||
| City: | KANE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 167351522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148378513 | ||||||||
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| Practice Location | |||||||||
| Address1: | 116 INTERSTATE PKWY | ||||||||
| Address2: | |||||||||
| City: | BRADFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 167011036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143684143 | ||||||||
| FaxNumber: | 8143628708 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | DN001025 | PA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.