MEDICARE: KELLY SIERRA RD LDN

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	164.005421	IL

General Provider Information

NPI Number	:	1447884549
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY SIERRA RD LDN

Provider Business Mailing Address
First Line	:	445 W ARLINGTON PL APT 4W
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-2779
Country	:	US
Telephone Number	:	630-706-1414
Fax Number	:

Provider Business Practice Location Address
First Line	:	561 W DIVERSEY PKWY STE 219
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-1682
Country	:	US
Telephone Number	:	630-706-1414
Fax Number	:

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

Provider Enumeration Date	:	02/27/2020
Last Update Date	:	02/27/2020

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