Healthcare Provider Details

I. General information

NPI: 1427653500
Provider Name (Legal Business Name): KELLEY MICHELLE ENCINAS RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2020
Last Update Date: 12/04/2020
Certification Date: 12/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 N 8TH ST
SHEBOYGAN WI
53081-4006
US

IV. Provider business mailing address

7126 TAMARACK CT
MEQUON WI
53092-8517
US

V. Phone/Fax

Practice location:
  • Phone: 920-459-6411
  • Fax:
Mailing address:
  • Phone: 818-825-3191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: