Provider Demographics
NPI:1164844262
Name:KNOTT, KELSEY (RD, LDN)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:KNOTT
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4125 N SHERIDAN RD STE 20
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-7174
Mailing Address - Country:US
Mailing Address - Phone:309-686-5920
Mailing Address - Fax:
Practice Address - Street 1:4125 N SHERIDAN RD STE 20
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-7174
Practice Address - Country:US
Practice Address - Phone:309-686-5920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-09
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164006117133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered