Provider Demographics
NPI:1558714626
Name:GUDENKAUF, KELLY (RD, LD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GUDENKAUF
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2309 DEVINE ST
Mailing Address - Street 2:SIMPLY NUTRITION
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29205-2422
Mailing Address - Country:US
Mailing Address - Phone:803-814-5392
Mailing Address - Fax:
Practice Address - Street 1:3500 DODGE ST
Practice Address - Street 2:1159 HY-VEE
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52003-5261
Practice Address - Country:US
Practice Address - Phone:563-583-5204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-13
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA083269133V00000X
SC1594133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered