Provider Demographics
NPI:1811142433
Name:KELLY, AMY LYNN (RD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:LYNN
Last Name:KELLY
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 1:2523 W CARRIAGE LN
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-2404
Mailing Address - Country:US
Mailing Address - Phone:636-227-7337
Mailing Address - Fax:
Practice Address - Street 1:254 CLARKSON RD
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MO
Practice Address - Zip Code:63011-2245
Practice Address - Country:US
Practice Address - Phone:636-227-7337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-24
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164004678133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric