Provider Demographics
NPI:1619722600
Name:MCKINNON, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MCKINNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3310 LAKEVIEW TRL
Mailing Address - Street 2:
Mailing Address - City:CANAL WINCHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:43110-8030
Mailing Address - Country:US
Mailing Address - Phone:419-350-8401
Mailing Address - Fax:
Practice Address - Street 1:3310 LAKEVIEW TRL
Practice Address - Street 2:
Practice Address - City:CANAL WINCHESTER
Practice Address - State:OH
Practice Address - Zip Code:43110-8030
Practice Address - Country:US
Practice Address - Phone:419-350-8401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-22
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered