Healthcare Provider Details

I. General information

NPI: 1750569539
Provider Name (Legal Business Name): KELLY PENDLETON RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY STEPHENS

II. Dates (important events)

Enumeration Date: 02/05/2008
Last Update Date: 02/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

592 FIELDSTOWN RD STE. 102 - CKD SERVICES OF GARDENDALE
GARDENDALE AL
35071-3414
US

IV. Provider business mailing address

209 KYLE CT
GARDENDALE AL
35071-2716
US

V. Phone/Fax

Practice location:
  • Phone: 205-608-3653
  • Fax: 205-608-3654
Mailing address:
  • Phone: 678-764-3940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number945221
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: