Provider Demographics
NPI:1376768655
Name:WILSON, DOROTHY B (MHS, RD, LDN)
Entity Type:Individual
Prefix:MRS
First Name:DOROTHY
Middle Name:B
Last Name:WILSON
Suffix:
Gender:F
Credentials:MHS, 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:PO BOX 364
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-0364
Mailing Address - Country:US
Mailing Address - Phone:708-747-3016
Mailing Address - Fax:708-668-7601
Practice Address - Street 1:17800 KEDZIE AVE
Practice Address - Street 2:FOOD & NUTRITION SERVICES
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-2029
Practice Address - Country:US
Practice Address - Phone:708-213-3053
Practice Address - Fax:708-213-0134
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
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