Provider Demographics
NPI:1942010178
Name:KELLEY, MARISSA ELAINE (RD, CDCES, NBC-HWC)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:ELAINE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:RD, CDCES, NBC-HWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23W308 WESTCHESTER CT
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-6546
Mailing Address - Country:US
Mailing Address - Phone:617-833-3783
Mailing Address - Fax:
Practice Address - Street 1:23W308 WESTCHESTER CT
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-6546
Practice Address - Country:US
Practice Address - Phone:617-833-3783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-09
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.005904133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered