Healthcare Provider Details

I. General information

NPI: 1053462804
Provider Name (Legal Business Name): KELLY IRENE NIBLETT RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLY IRENE PELCHAT RD

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6201 N SUNCOAST BLVD
CRYSTAL RIVER FL
34428-6712
US

IV. Provider business mailing address

3138 N BOSWELL TER
HERNANDO FL
34442-4732
US

V. Phone/Fax

Practice location:
  • Phone: 352-795-6560
  • Fax:
Mailing address:
  • Phone: 352-746-3862
  • Fax: 352-795-8409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND4304
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: