Provider Demographics
NPI:1801095963
Name:CUFFE, KELLY LYNN (RD, LD, CDE)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:LYNN
Last Name:CUFFE
Suffix:
Gender:F
Credentials:RD, LD, CDE
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:LYNN
Other - Last Name:POWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 FITNESS DR
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-9584
Mailing Address - Country:US
Mailing Address - Phone:815-936-6515
Mailing Address - Fax:815-936-6517
Practice Address - Street 1:350 N WALL ST
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-2901
Practice Address - Country:US
Practice Address - Phone:815-936-6515
Practice Address - Fax:815-936-6517
Is Sole Proprietor?:No
Enumeration Date:2007-07-17
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.003315133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered