Provider Demographics
NPI:1346792744
Name:MCNULTY, STEPHANIE (RD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:MCNULTY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 E HAWTHORN PKWY
Mailing Address - Street 2:SUITE 235
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-1463
Mailing Address - Country:US
Mailing Address - Phone:847-868-3435
Mailing Address - Fax:
Practice Address - Street 1:1689 N CURRAN RD
Practice Address - Street 2:SUITE 202
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-6541
Practice Address - Country:US
Practice Address - Phone:847-868-3435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-01
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164006896133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered