Healthcare Provider Details

I. General information

NPI: 1962671149
Provider Name (Legal Business Name): KELLY VANALLEN-BRASWELL RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2008
Last Update Date: 02/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 ROTHERMEL AVE
KINDERHOOK NY
12106-2105
US

IV. Provider business mailing address

PO BOX 3
KINDERHOOK NY
12106-0003
US

V. Phone/Fax

Practice location:
  • Phone: 518-758-8885
  • Fax:
Mailing address:
  • Phone: 518-758-8885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number006035-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: