Provider Demographics
NPI:1417576042
Name:WILMES, KELLI JO (RD, LD)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:JO
Last Name:WILMES
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12847 STATE HIGHWAY YY
Mailing Address - Street 2:
Mailing Address - City:ELMO
Mailing Address - State:MO
Mailing Address - Zip Code:64445-8209
Mailing Address - Country:US
Mailing Address - Phone:660-215-2046
Mailing Address - Fax:
Practice Address - Street 1:12847 STATE HIGHWAY YY
Practice Address - Street 2:
Practice Address - City:ELMO
Practice Address - State:MO
Practice Address - Zip Code:64445-8209
Practice Address - Country:US
Practice Address - Phone:660-215-2046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-14
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA099245133V00000X
MO2009028340133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered