Healthcare Provider Details

I. General information

NPI: 1952752164
Provider Name (Legal Business Name): KELLY WEST KEYSER RD, LD, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRS. KELLY WEST

II. Dates (important events)

Enumeration Date: 06/29/2016
Last Update Date: 09/14/2021
Certification Date: 09/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5361 MEADOW BROOK RD
BIRMINGHAM AL
35242-3340
US

IV. Provider business mailing address

5361 MEADOW BROOK RD
BIRMINGHAM AL
35242-3340
US

V. Phone/Fax

Practice location:
  • Phone: 205-213-0410
  • Fax:
Mailing address:
  • Phone: 205-213-0410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number2604
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2604
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: