Healthcare Provider Details

I. General information

NPI: 1790928679
Provider Name (Legal Business Name): KELLY ANN HOFSESS M.S.R.D.L.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2009
Last Update Date: 04/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

888 BOARDMAN CANFIELD RD SUITE I.
BOARDMAN OH
44512-4276
US

IV. Provider business mailing address

888 BOARDMAN CANFIELD RD SUITE I.
BOARDMAN OH
44512-4276
US

V. Phone/Fax

Practice location:
  • Phone: 330-726-2440
  • Fax: 330-726-6844
Mailing address:
  • Phone: 330-726-2440
  • Fax: 330-726-6844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2178
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: