Basic Information
Provider Information | |||||||||
NPI: | 1801095963 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CUFFE | ||||||||
FirstName: | KELLY | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | RD, LD, CDE | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | POWELL | ||||||||
OtherFirstName: | KELLY | ||||||||
OtherMiddleName: | LYNN | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 100 FITNESS DR | ||||||||
Address2: |   | ||||||||
City: | BOURBONNAIS | ||||||||
State: | IL | ||||||||
PostalCode: | 609149584 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8159366515 | ||||||||
FaxNumber: | 8159366517 | ||||||||
Practice Location | |||||||||
Address1: | 350 N WALL ST | ||||||||
Address2: |   | ||||||||
City: | KANKAKEE | ||||||||
State: | IL | ||||||||
PostalCode: | 609012901 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8159366515 | ||||||||
FaxNumber: | 8159366517 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/17/2007 | ||||||||
LastUpdateDate: | 10/10/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 164.003315 | IL | Y |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   |
No ID Information.