Provider Demographics
NPI:1003001405
Name:DEVINE, KELLY L (MS, RDN, LDN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:DEVINE
Suffix:
Gender:F
Credentials:MS, RDN, LDN
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:L
Other - Last Name:DEVINE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS RDN LDN
Mailing Address - Street 1:6521 CHARLESTON ST
Mailing Address - Street 2:
Mailing Address - City:OAK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60452-2626
Mailing Address - Country:US
Mailing Address - Phone:708-612-0876
Mailing Address - Fax:
Practice Address - Street 1:6811 167TH ST STE 6
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-2501
Practice Address - Country:US
Practice Address - Phone:708-608-9014
Practice Address - Fax:708-377-0060
Is Sole Proprietor?:No
Enumeration Date:2007-09-09
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.004722133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK47013/204133Medicare PIN