Provider Demographics
NPI:1376231696
Name:SHELTON, KENYATTA
Entity Type:Individual
Prefix:
First Name:KENYATTA
Middle Name:
Last Name:SHELTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5135 W WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60644-3441
Mailing Address - Country:US
Mailing Address - Phone:773-642-7314
Mailing Address - Fax:
Practice Address - Street 1:5135 W WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60644-3441
Practice Address - Country:US
Practice Address - Phone:773-642-7314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-25
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL131014391136A00000X, 247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherGroup - Single Specialty
No136A00000XDietary & Nutritional Service ProvidersDietetic Technician, RegisteredGroup - Single Specialty