Provider Demographics
NPI:1366678153
Name:NIEWINSKI, MARY M (MS, RD, LDN)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:M
Last Name:NIEWINSKI
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5424 N NASHVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60656-2209
Mailing Address - Country:US
Mailing Address - Phone:773-456-4201
Mailing Address - Fax:312-355-0739
Practice Address - Street 1:5424 N NASHVILLE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60656-2209
Practice Address - Country:US
Practice Address - Phone:773-456-4201
Practice Address - Fax:312-355-0739
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-07
Last Update Date:2009-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133VN1004X, 133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic