Provider Demographics
NPI:1285010363
Name:ALLEN, TARA (MS, RDN, LDN)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:ALLEN
Suffix:
Gender:F
Credentials:MS, RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35318 EAGLE WAY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60678-1353
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:3700 W 203RD ST STE 310
Practice Address - Street 2:
Practice Address - City:OLYMPIA FLDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1182
Practice Address - Country:US
Practice Address - Phone:708-679-2130
Practice Address - Fax:708-679-2260
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-30
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.006439133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered