MEDICARE: KELLY ST JOHN RD, CSO, LDN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133VN1301X	Oncology Nutrition Registered Dietitian	DN006824	PA

General Provider Information

NPI Number	:	1205766011
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY ST JOHN RD, CSO, LDN

Provider Business Mailing Address
First Line	:	333 COTTMAN AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19111-2497
Country	:	US
Telephone Number	:	215-870-9315
Fax Number	:

Provider Business Practice Location Address
First Line	:	333 COTTMAN AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19111-2497
Country	:	US
Telephone Number	:	215-870-9315
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/22/2026
Last Update Date	:	05/22/2026

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