=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003001405
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY L DEVINE MS, RDN, LDN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2007
-----------------------------------------------------
Last Update Date | 03/10/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10847 W LAPORTE
-----------------------------------------------------
City | MOKENA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-608-9014
-----------------------------------------------------
Fax | 708-377-0060
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6521 CHARLESTON ST
-----------------------------------------------------
City | OAK FOREST
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60452-2626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-612-0876
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | 164.004722
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------