Provider Demographics
NPI:1073251724
Name:MINARICK, KELLY WYNNE (RD, RDN, LDN)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:WYNNE
Last Name:MINARICK
Suffix:
Gender:F
Credentials:RD, RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17060 DALLAS PKWY STE 112
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248-1905
Mailing Address - Country:US
Mailing Address - Phone:469-372-2022
Mailing Address - Fax:833-290-5413
Practice Address - Street 1:650 WARRENVILLE RD STE 100
Practice Address - Street 2:
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-4315
Practice Address - Country:US
Practice Address - Phone:847-318-3013
Practice Address - Fax:833-290-5413
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-23
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.007272133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered