Provider Demographics
NPI:1093908881
Name:HICKS-BLUE, PENNI JO (RD, LDN)
Entity Type:Individual
Prefix:MRS
First Name:PENNI
Middle Name:JO
Last Name:HICKS-BLUE
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 E PLEASANT AVE
Mailing Address - Street 2:
Mailing Address - City:SANDWICH
Mailing Address - State:IL
Mailing Address - Zip Code:60548-1100
Mailing Address - Country:US
Mailing Address - Phone:815-786-3719
Mailing Address - Fax:
Practice Address - Street 1:11 E PLEASANT AVE
Practice Address - Street 2:
Practice Address - City:SANDWICH
Practice Address - State:IL
Practice Address - Zip Code:60548-1100
Practice Address - Country:US
Practice Address - Phone:815-786-3719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-24
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered