Healthcare Provider Details

I. General information

NPI: 1386146827
Provider Name (Legal Business Name): KELLY KOSS MS, RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2018
Last Update Date: 02/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 N VERMONT AVE
LOS ANGELES CA
90027-6098
US

IV. Provider business mailing address

425 N ALVARADO ST APT 102
LOS ANGELES CA
90026-4959
US

V. Phone/Fax

Practice location:
  • Phone: 847-602-6399
  • Fax:
Mailing address:
  • Phone: 847-602-6399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number283972
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1043908
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: