Provider Demographics
NPI:1396325288
Name:KINGSLEY, ELLI L (RD,LD)
Entity type:Individual
Prefix:
First Name:ELLI
Middle Name:L
Last Name:KINGSLEY
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 1:4809 ROANOKE PKWY APT 606
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64112-2032
Mailing Address - Country:US
Mailing Address - Phone:316-308-1208
Mailing Address - Fax:
Practice Address - Street 1:16979 W 94TH ST STE D
Practice Address - Street 2:
Practice Address - City:LENEXA
Practice Address - State:KS
Practice Address - Zip Code:66219-1939
Practice Address - Country:US
Practice Address - Phone:316-308-1208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-13
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019036337133V00000X
KS2241133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered