Provider Demographics
NPI:1689250953
Name:WAGNER, KELLY ANN (RD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:WAGNER
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 1:3530 N RETA AVE APT 2R
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-6912
Mailing Address - Country:US
Mailing Address - Phone:630-776-5461
Mailing Address - Fax:
Practice Address - Street 1:3530 N RETA AVE APT 2R
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-6912
Practice Address - Country:US
Practice Address - Phone:630-776-5461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-18
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL006355133V00000X
IL164.007063133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered