Provider Demographics
NPI:1659613438
Name:REESER, KELLY NICOLE (RD)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:NICOLE
Last Name:REESER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:N
Other - Last Name:LESKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:4202 W OAKWOOD PARK CT
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-9118
Practice Address - Country:US
Practice Address - Phone:414-423-5250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-20
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1069975133V00000X
WI5442-29133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered