Kelly Wynne Minarick, RD, RDN, LDN

Primary specialty

Registered DietitianTaxonomy code 133V00000X

License

164.007272 Issued in IL

Practice address

650 Warrenville Rd Ste 100
Lisle, IL 60532-4315

Phone

(847) 318-3013

Fax

(833) 290-5413

NPI assigned

May 23, 2022

Last updated

Mar 21, 2024By the provider in NPPES

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in IL

Enrollment records 1

Specialty

Registered Dietitian Or Nutrition Professional

Education

Other, 2017

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Doherty Nutrition LLCGroup PAC ID 0941610273, 16 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Doherty Nutrition LLC

  • Registered Dietitian
  • Dallas, TX
  • NPI 1326502832

  Dietitian, Registered, IL

  Medicare reassignment Care Compare group NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1653264000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1710979200000",
    "number": "1073251724",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "17060 DALLAS PKWY STE 112",
            "city": "DALLAS",
            "state": "TX",
            "postal_code": "752481905",
            "telephone_number": "469-372-2022",
            "fax_number": "833-290-5413"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "650 WARRENVILLE RD STE 100",
            "city": "LISLE",
            "state": "IL",
            "postal_code": "605324315",
            "telephone_number": "847-318-3013",
            "fax_number": "833-290-5413"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "17060 Dallas Pkwy Ste 112",
            "address_purpose": "LOCATION",
            "city": "Dallas",
            "state": "TX",
            "postal_code": "752481905",
            "country_code": "US",
            "telephone_number": "469-372-2022",
            "fax_number": "833-290-5413",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "MINARICK",
        "first_name": "KELLY",
        "middle_name": "WYNNE",
        "name_prefix": "Mrs.",
        "credential": "RD, RDN, LDN",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2022-05-23",
        "last_updated": "2024-03-21",
        "certification_date": "2024-03-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "133V00000X",
            "taxonomy_group": "",
            "desc": "Dietitian, Registered",
            "state": "IL",
            "license": "164.007272",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Registered Dietitian in Lisle, IL
• Providers in Lisle, IL by specialty
• Registered Dietitian in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 21, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.