Provider Demographics
NPI:1417180787
Name:BRASSEUR, KELLY JEAN (MS, RD, LDN)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:JEAN
Last Name:BRASSEUR
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 1:4201 MEDICAL CENTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050
Mailing Address - Country:US
Mailing Address - Phone:815-759-4146
Mailing Address - Fax:815-759-8072
Practice Address - Street 1:4201 MEDICAL CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050
Practice Address - Country:US
Practice Address - Phone:815-759-4146
Practice Address - Fax:815-759-8072
Is Sole Proprietor?:No
Enumeration Date:2009-09-02
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.002765133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered