MEDICARE: MS. BEVERLY KAY KELLEY RD,LD,CDE

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	LD472	OK

General Provider Information

NPI Number	:	1356788400
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. BEVERLY KAY KELLEY RD,LD,CDE

Provider Business Mailing Address
First Line	:	1717B S UTICA AVE
Second Line	:	SUITE 205
City	:	TULSA
State	:	OK
Zip	:	74104-5333
Country	:	US
Telephone Number	:	918-744-2273
Fax Number	:	918-744-2483

Provider Business Practice Location Address
First Line	:	1717B S UTICA AVE
Second Line	:	SUITE 205
City	:	TULSA
State	:	OK
Zip	:	74104-5333
Country	:	US
Telephone Number	:	918-744-2273
Fax Number	:	918-744-2483

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

Provider Enumeration Date	:	05/30/2013
Last Update Date	:	05/30/2013

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