Healthcare Provider Details

I. General information

NPI: 1609706878
Provider Name (Legal Business Name): KEITH BRATLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 CALABASH CT
SALISBURY MD
21804-2432
US

IV. Provider business mailing address

408 CALABASH CT
SALISBURY MD
21804-2432
US

V. Phone/Fax

Practice location:
  • Phone: 410-924-0446
  • Fax:
Mailing address:
  • Phone: 410-924-0446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN-0011358
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDX5966
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: