Provider Demographics
NPI:1235750167
Name:BROOKS, KELLY (RD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BROOKS
Suffix:
Gender:
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1132 BERGEN ST APT 3F
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216-3388
Mailing Address - Country:US
Mailing Address - Phone:203-885-2757
Mailing Address - Fax:
Practice Address - Street 1:445 LENOX RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2017
Practice Address - Country:US
Practice Address - Phone:718-270-3366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-01
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86058036133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered