Provider Demographics
NPI:1326062415
Name:O'HERON, KELLY C (RD CD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:C
Last Name:O'HERON
Suffix:
Gender:
Credentials:RD CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:WI
Mailing Address - Zip Code:53925-2402
Mailing Address - Country:US
Mailing Address - Phone:920-623-2200
Mailing Address - Fax:
Practice Address - Street 1:1515 PARK AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:WI
Practice Address - Zip Code:53925-2402
Practice Address - Country:US
Practice Address - Phone:920-623-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2025-03-03
Deactivation Date:2017-10-25
Deactivation Code:
Reactivation Date:2023-02-21
Provider Licenses
StateLicense IDTaxonomies
WI1939133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI490905189007OtherANTHEM BC/BS