MEDICARE: GRACE KELLEY NUTRITION LLC

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	133VN1501X	Sports Dietetics Nutrition Registered Dietitian
2	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1740136712
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACE KELLEY NUTRITION LLC

Provider Business Mailing Address
First Line	:	2909 N SHERIDAN RD APT 1806
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-5946
Country	:	US
Telephone Number	:	440-986-0360
Fax Number	:

Provider Business Practice Location Address
First Line	:	3838 N RAVENSWOOD AVE # 308
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-5651
Country	:	US
Telephone Number	:	440-986-0360
Fax Number	:

Authorized Official
Title or Position	:	SPORTS DIETITIAN
Name	:	GRACE A KELLEY
Credential	:	RDN, LD
Telephone Number	:	440-986-0360

Provider Enumeration Date	:	03/10/2026
Last Update Date	:	03/10/2026

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