Provider Demographics
NPI:1497126312
Name:KLECKNER, KELLY (RD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KLECKNER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 N FAIRBANKS CT
Mailing Address - Street 2:7-121
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3013
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:710 N FAIRBANKS CT
Practice Address - Street 2:7-121
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3013
Practice Address - Country:US
Practice Address - Phone:312-926-7437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-19
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1003448133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered