MEDICARE: GRACE KELLEY

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	86174599	OH

General Provider Information

NPI Number	:	1962149617
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRACE KELLEY

Provider Business Mailing Address
First Line	:	1400 KINGSWAY
Second Line	:
City	:	WESTLAKE
State	:	OH
Zip	:	44145-2613
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1830 W 28TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44113-3064
Country	:	US
Telephone Number	:	440-986-0360
Fax Number	:

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

Provider Enumeration Date	:	05/15/2022
Last Update Date	:	12/05/2024

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Directions to “ GRACE KELLEY ” Practice Location

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