Healthcare Provider Details

I. General information

NPI: 1093105124
Provider Name (Legal Business Name): KELLY LAZZELL R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2015
Last Update Date: 01/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N JORDAN AVE
BLOOMINGTON IN
47405-3190
US

IV. Provider business mailing address

526 N GRANT ST 3A
BLOOMINGTON IN
47408-3665
US

V. Phone/Fax

Practice location:
  • Phone: 812-855-4011
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: