Provider Demographics
NPI:1770548711
Name:MCDONNELL, KELLY A (RD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:MCDONNELL
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 1:11523 TEA TREE LN
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-5118
Mailing Address - Country:US
Mailing Address - Phone:815-603-4793
Mailing Address - Fax:
Practice Address - Street 1:500 W COURT ST
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-3661
Practice Address - Country:US
Practice Address - Phone:815-937-2454
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK23790Medicare ID - Type Unspecified