Provider Demographics
NPI:1790311991
Name:WEBSTER, KELLY M (RDN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:WEBSTER
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 1:1079 DICKENS DR
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-4314
Mailing Address - Country:US
Mailing Address - Phone:262-443-9991
Mailing Address - Fax:
Practice Address - Street 1:W227N6103 SUSSEX RD
Practice Address - Street 2:
Practice Address - City:SUSSEX
Practice Address - State:WI
Practice Address - Zip Code:53089-3969
Practice Address - Country:US
Practice Address - Phone:414-566-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-19
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI888691174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator