Healthcare Provider Details

I. General information

NPI: 1538100292
Provider Name (Legal Business Name): KELLY E BARR RD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 W 6TH ST MC # 49
JACKSONVILLE FL
32206-4324
US

IV. Provider business mailing address

515 W 6TH ST MC #24
JACKSONVILLE FL
32206-4324
US

V. Phone/Fax

Practice location:
  • Phone: 904-665-2533
  • Fax: 904-832-5340
Mailing address:
  • Phone: 904-665-2410
  • Fax: 904-630-3316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberND4871
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: