Provider Demographics
NPI:1437800760
Name:BROWN, KELLY (MS, RD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3041 CASTLE PEAK AVE
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:CO
Mailing Address - Zip Code:80027-6071
Mailing Address - Country:US
Mailing Address - Phone:317-220-9809
Mailing Address - Fax:
Practice Address - Street 1:3455 LUTHERAN PKWY
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-6028
Practice Address - Country:US
Practice Address - Phone:303-403-3039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-18
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86021227133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
86021227OtherRD LICENSURE