Provider Demographics
NPI:1164488920
Name:LIETZ, ANNE M (RD)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:M
Last Name:LIETZ
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:ANNE
Other - Middle Name:M
Other - Last Name:DRALLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1419 GREEN TRAILS DR
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60586-7613
Mailing Address - Country:US
Mailing Address - Phone:815-577-8173
Mailing Address - Fax:
Practice Address - Street 1:333 MADISON ST
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-8200
Practice Address - Country:US
Practice Address - Phone:815-723-7133
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00152372OtherRAILROAD MEDICARE
ILK04849Medicare ID - Type Unspecified