MEDICARE: KELLEY WISSINGER R.D.

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	01024659	TX

General Provider Information

NPI Number	:	1588974810
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLEY WISSINGER R.D.

Provider Business Mailing Address
First Line	:	9404 MILL HOLLOW DR
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75243-6338
Country	:	US
Telephone Number	:	972-921-4669
Fax Number	:

Provider Business Practice Location Address
First Line	:	9404 MILL HOLLOW DR
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75243-6338
Country	:	US
Telephone Number	:	972-921-4669
Fax Number	:

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

Provider Enumeration Date	:	10/20/2010
Last Update Date	:	01/22/2020

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