Healthcare Provider Details

I. General information

NPI: 1689160566
Provider Name (Legal Business Name): KELLY STAPLETON RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2018
Last Update Date: 07/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3630 E IMPERIAL HWY
LYNWOOD CA
90262-2609
US

IV. Provider business mailing address

6100 S PACIFIC COAST HWY APT 14
REDONDO BEACH CA
90277-5957
US

V. Phone/Fax

Practice location:
  • Phone: 310-900-7867
  • Fax:
Mailing address:
  • Phone: 617-224-3923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number86018613
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: