Provider Demographics
NPI:1508030073
Name:KELLY, ERIN M (RD, LDN)
Entity Type:Individual
Prefix:MRS
First Name:ERIN
Middle Name:M
Last Name:KELLY
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 1:33 N. RIDGEMOOR AVE
Mailing Address - Street 2:
Mailing Address - City:MUNDELEIN
Mailing Address - State:IL
Mailing Address - Zip Code:60060
Mailing Address - Country:US
Mailing Address - Phone:847-636-3786
Mailing Address - Fax:
Practice Address - Street 1:3001 GREEN BAY ROAD
Practice Address - Street 2:
Practice Address - City:NORTH CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60064
Practice Address - Country:US
Practice Address - Phone:847-636-3786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-16
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL91589OtherMEDICARE PART B
ILL91589OtherMEDICARE PART B