Healthcare Provider Details

I. General information

NPI: 1083054993
Provider Name (Legal Business Name): MICHAEL ANN KELLY M.S., R.D., L.D.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2013
Last Update Date: 06/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 KISH HOSPITAL DR
DEKALB IL
60115-9602
US

IV. Provider business mailing address

205 W SOUTH ST
DWIGHT IL
60420-1238
US

V. Phone/Fax

Practice location:
  • Phone: 815-756-1521
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.005938
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: