Provider Demographics
NPI:1124678578
Name:ROBERTS, KENNETH ANDRE II (MA, RD, LDN)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:ANDRE
Last Name:ROBERTS
Suffix:II
Gender:M
Credentials:MA, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:922A TALON DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1848
Mailing Address - Country:US
Mailing Address - Phone:618-671-6501
Mailing Address - Fax:
Practice Address - Street 1:922A TALON DR
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1848
Practice Address - Country:US
Practice Address - Phone:618-688-2038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-18
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019029751133V00000X
IL164.007826133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered