Provider Demographics
NPI:1083794135
Name:HOCHHALTER, KELLIE C (RD)
Entity Type:Individual
Prefix:MS
First Name:KELLIE
Middle Name:C
Last Name:HOCHHALTER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:C
Other - Last Name:SPEIDEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 ELM STREET NORTH
Mailing Address - Street 2:
Mailing Address - City:ONAMIA
Mailing Address - State:MN
Mailing Address - Zip Code:56359
Mailing Address - Country:US
Mailing Address - Phone:320-532-3154
Mailing Address - Fax:320-532-3111
Practice Address - Street 1:1025 MARSH ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-4752
Practice Address - Country:US
Practice Address - Phone:507-625-4031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2576133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND55808Medicaid
ND55808Medicaid
MN710000515Medicare ID - Type Unspecified