Provider Demographics
NPI:1588266613
Name:WALKER, KELLY (MS, RD, LDN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WALKER
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12245 N 1800TH ST
Mailing Address - Street 2:
Mailing Address - City:PALESTINE
Mailing Address - State:IL
Mailing Address - Zip Code:62451-2728
Mailing Address - Country:US
Mailing Address - Phone:618-553-5467
Mailing Address - Fax:
Practice Address - Street 1:12245 N 1800TH ST
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:IL
Practice Address - Zip Code:62451-2728
Practice Address - Country:US
Practice Address - Phone:618-553-5467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-13
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164005007133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered