Provider Demographics
NPI:1396369013
Name:GILLIE MELTON, SARA (RD, LDN)
Entity Type:Individual
Prefix:MRS
First Name:SARA
Middle Name:
Last Name:GILLIE MELTON
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:MS
Other - First Name:SARA
Other - Middle Name:
Other - Last Name:GILLIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:426 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409-2259
Mailing Address - Country:US
Mailing Address - Phone:708-870-7233
Mailing Address - Fax:
Practice Address - Street 1:426 MADISON AVE
Practice Address - Street 2:
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409-2259
Practice Address - Country:US
Practice Address - Phone:708-870-7233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-29
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.004821133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered