Healthcare Provider Details

I. General information

NPI: 1962677252
Provider Name (Legal Business Name): KELLY D PANEITZ R.D., L.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2008
Last Update Date: 04/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 SAPPINGTON BRIDGE RD MISSOURI BAPTIST HOSPITAL - SULLIVAN
SULLIVAN MO
63080-2354
US

IV. Provider business mailing address

751 SAPPINGTON BRIDGE RD MISSOURI BAPTIST HOSPITAL - SULLIVAN
SULLIVAN MO
63080-2354
US

V. Phone/Fax

Practice location:
  • Phone: 573-468-1347
  • Fax: 573-468-1125
Mailing address:
  • Phone: 573-468-1347
  • Fax: 573-468-1125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2001012812
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: