Provider Demographics
NPI:1871895730
Name:FENTRESS, KELSEY DANAE (RD)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:DANAE
Last Name:FENTRESS
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 1:1192 TEN MILE RD
Mailing Address - Street 2:
Mailing Address - City:BONIFAY
Mailing Address - State:FL
Mailing Address - Zip Code:32425-6208
Mailing Address - Country:US
Mailing Address - Phone:270-348-0442
Mailing Address - Fax:
Practice Address - Street 1:1192 TEN MILE RD
Practice Address - Street 2:
Practice Address - City:BONIFAY
Practice Address - State:FL
Practice Address - Zip Code:32425-6208
Practice Address - Country:US
Practice Address - Phone:270-348-0442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-29
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK174366133V00000X
FLND12329133V00000X
KY2306133V00000X
AL5276133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP400034574Medicare PIN