Provider Demographics
NPI:1417529900
Name:KETNER, TARA (RDN, LDN)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:KETNER
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2607 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IL
Mailing Address - Zip Code:61354-1563
Mailing Address - Country:US
Mailing Address - Phone:815-883-1788
Mailing Address - Fax:
Practice Address - Street 1:920 WEST ST
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-2763
Practice Address - Country:US
Practice Address - Phone:815-780-3520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL86212286133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered