Provider Demographics
NPI:1609456896
Name:ROMENESKO, KENNEDI (RDN)
Entity Type:Individual
Prefix:MRS
First Name:KENNEDI
Middle Name:
Last Name:ROMENESKO
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 S CLEAR LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:WI
Mailing Address - Zip Code:53563-1107
Mailing Address - Country:US
Mailing Address - Phone:920-931-5541
Mailing Address - Fax:
Practice Address - Street 1:123 S CLEAR LAKE AVE
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:WI
Practice Address - Zip Code:53563-1107
Practice Address - Country:US
Practice Address - Phone:920-931-5541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-12
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI86253884Medicaid