Healthcare Provider Details

I. General information

NPI: 1376231696
Provider Name (Legal Business Name): KENYATTA SHELTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2023
Last Update Date: 04/25/2023
Certification Date: 04/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5135 W WASHINGTON BLVD
CHICAGO IL
60644-3441
US

IV. Provider business mailing address

5135 W WASHINGTON BLVD
CHICAGO IL
60644-3441
US

V. Phone/Fax

Practice location:
  • Phone: 773-642-7314
  • Fax:
Mailing address:
  • Phone: 773-642-7314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code136A00000X
TaxonomyRegistered Dietetic Technician
License Number131014391
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number131014391
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: