MEDICARE: KELLY GOWETT RD

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	998601	NY

General Provider Information

NPI Number	:	1831688837
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY GOWETT RD

Provider Business Mailing Address
First Line	:	128 BOYNTON AVE
Second Line	:
City	:	PLATTSBURGH
State	:	NY
Zip	:	12901-1237
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	128 BOYNTON AVE
Second Line	:
City	:	PLATTSBURGH
State	:	NY
Zip	:	12901-1237
Country	:	US
Telephone Number	:	518-324-3399
Fax Number	:

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

Provider Enumeration Date	:	05/04/2018
Last Update Date	:	05/04/2018

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