Healthcare Provider Details

I. General information

NPI: 1619127305
Provider Name (Legal Business Name): KELLY E. HAMLIN RD, CDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2008
Last Update Date: 09/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 MIDDLE BRANCH RD
OLD FORGE NY
13420
US

IV. Provider business mailing address

PO BOX 213
OLD FORGE NY
13420-0213
US

V. Phone/Fax

Practice location:
  • Phone: 315-369-2313
  • Fax:
Mailing address:
  • Phone: 315-369-2313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number005683-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: