Provider Demographics
NPI:1063832269
Name:KENNEDY, KATE MELISSA (RDN, LDN, NASM-CPT)
Entity Type:Individual
Prefix:
First Name:KATE
Middle Name:MELISSA
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:RDN, LDN, NASM-CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6596 N OGALLAH AVE APT 1B
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-1560
Mailing Address - Country:US
Mailing Address - Phone:737-936-5619
Mailing Address - Fax:
Practice Address - Street 1:6596 N OGALLAH AVE APT 1B
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-1560
Practice Address - Country:US
Practice Address - Phone:737-936-5619
Practice Address - Fax:708-680-0124
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-26
Last Update Date:2022-03-28
Deactivation Date:2014-06-11
Deactivation Code:
Reactivation Date:2014-07-01
Provider Licenses
StateLicense IDTaxonomies
133V00000X
IL164.005669133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered