Healthcare Provider Details

I. General information

NPI: 1588664387
Provider Name (Legal Business Name): KELLI ANDERSON LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 INTERSTATE PKWY
BRADFORD PA
16701-1036
US

IV. Provider business mailing address

630 GREEVES ST
KANE PA
16735-1522
US

V. Phone/Fax

Practice location:
  • Phone: 814-368-4143
  • Fax: 814-362-8708
Mailing address:
  • Phone: 814-837-8513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN001025
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: