MEDICARE: MRS. KELLY NICOLE DERWICK RDN, LN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	10167	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	10167	OTHER	FL	FLORIDA DEPARTMENT OF HEALTH

General Provider Information

NPI Number	:	1033715727
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLY NICOLE DERWICK RDN, LN

Provider Business Mailing Address
First Line	:	119 SE 39TH ST
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33904-8338
Country	:	US
Telephone Number	:	239-910-3871
Fax Number	:

Provider Business Practice Location Address
First Line	:	119 SE 39TH ST
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33904
Country	:	US
Telephone Number	:	239-910-3871
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/08/2020
Last Update Date	:	05/04/2026

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