MEDICARE: MRS. KELLY SARAH SCHOOLEY RD LD/N CLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	ND 5836	FL

General Provider Information

NPI Number	:	1376845172
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLY SARAH SCHOOLEY RD LD/N CLC

Provider Business Mailing Address
First Line	:	3466 NIGHTSCAPE CIR
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32224-1618
Country	:	US
Telephone Number	:	904-307-9275
Fax Number	:

Provider Business Practice Location Address
First Line	:	5322 N PEARL ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32208-5119
Country	:	US
Telephone Number	:	904-253-2533
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2010
Last Update Date	:	08/03/2012

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