Provider Demographics
NPI:1003104860
Name:ALICEA MATOS, VANESSA (RD)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:ALICEA MATOS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:VANESSA
Other - Middle Name:
Other - Last Name:ALICEA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:2003 W FULTON ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-2345
Mailing Address - Country:US
Mailing Address - Phone:312-850-3438
Mailing Address - Fax:312-638-9872
Practice Address - Street 1:2003 W FULTON ST
Practice Address - Street 2:SUITE 105
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-2345
Practice Address - Country:US
Practice Address - Phone:312-850-3438
Practice Address - Fax:312-638-9872
Is Sole Proprietor?:No
Enumeration Date:2011-07-14
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164005257133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL164005257OtherLICENSE