Healthcare Provider Details

I. General information

NPI: 1104222652
Provider Name (Legal Business Name): KELLY L SCOTT RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2014
Last Update Date: 01/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

819 SOUTHWESTERN RUN
YOUNGSTOWN OH
44514-3688
US

IV. Provider business mailing address

1755 ISLAND DR
POLAND OH
44514-5603
US

V. Phone/Fax

Practice location:
  • Phone: 330-629-9991
  • Fax:
Mailing address:
  • Phone: 330-550-3655
  • Fax: 888-482-5741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD.6119
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: