Basic Information
| Provider Information | |||||||||
| NPI: | 1922061332 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POWELL | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | GRIFFIN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | RD, CDE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19636 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627949636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175453821 | ||||||||
| FaxNumber: | 2175451229 | ||||||||
| Practice Location | |||||||||
| Address1: | 751 N RUTLEDGE ST | ||||||||
| Address2: | RM 2300 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627024909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175453821 | ||||||||
| FaxNumber: | 2175451229 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2006 | ||||||||
| LastUpdateDate: | 03/10/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 164-000416 | IL | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.