Healthcare Provider Details

I. General information

NPI: 1063832269
Provider Name (Legal Business Name): KATE MELISSA KENNEDY RDN, LDN, NASM-CPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2014
Last Update Date: 03/28/2022
Certification Date: 03/28/2022
Deactivation Date: 06/11/2014
Reactivation Date: 07/01/2014

III. Provider practice location address

6596 N OGALLAH AVE APT 1B
CHICAGO IL
60631-1560
US

IV. Provider business mailing address

6596 N OGALLAH AVE APT 1B
CHICAGO IL
60631-1560
US

V. Phone/Fax

Practice location:
  • Phone: 737-936-5619
  • Fax: 708-680-0124
Mailing address:
  • Phone: 737-936-5619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.005669
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: