Provider Demographics
NPI:1083054993
Name:KELLY, MICHAEL ANN (MS, RD, LDN)
Entity Type:Individual
Prefix:MS
First Name:MICHAEL
Middle Name:ANN
Last Name:KELLY
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 W SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:DWIGHT
Mailing Address - State:IL
Mailing Address - Zip Code:60420-1238
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 KISH HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-9602
Practice Address - Country:US
Practice Address - Phone:815-756-1521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.005938133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered