Healthcare Provider Details

I. General information

NPI: 1881083988
Provider Name (Legal Business Name): MARY CLARE KELLEY R.D.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2015
Last Update Date: 01/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6001 N MAYFAIR ST
SPOKANE WA
99208-1129
US

IV. Provider business mailing address

PO BOX 996
HAYDEN ID
83835-0996
US

V. Phone/Fax

Practice location:
  • Phone: 509-462-2273
  • Fax: 509-462-2275
Mailing address:
  • Phone: 208-664-4026
  • Fax: 855-532-5921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code136A00000X
TaxonomyRegistered Dietetic Technician
License Number86009851
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: