Healthcare Provider Details

I. General information

NPI: 1518177112
Provider Name (Legal Business Name): MARY LYNN KARDELL RD, LMNT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 04/04/2025
Certification Date: 04/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21919 PIERCE CIR
ELKHORN NE
68022-1709
US

IV. Provider business mailing address

21919 PIERCE CIR
ELKHORN NE
68022-1709
US

V. Phone/Fax

Practice location:
  • Phone: 402-630-7415
  • Fax: 844-755-6400
Mailing address:
  • Phone: 402-630-7415
  • Fax: 844-755-6400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number742
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number726190
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: