Provider Demographics
NPI:1447884549
Name:SIERRA, KELLY (RD LDN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SIERRA
Suffix:
Gender:F
Credentials:RD LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 W ARLINGTON PL APT 4W
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-2779
Mailing Address - Country:US
Mailing Address - Phone:630-706-1414
Mailing Address - Fax:
Practice Address - Street 1:561 W DIVERSEY PKWY STE 219
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1682
Practice Address - Country:US
Practice Address - Phone:630-706-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-27
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.005421133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered