Provider Demographics
NPI:1417183625
Name:BUISHAS SIDLER, JENNINE MARIE (RD, LDN)
Entity Type:Individual
Prefix:
First Name:JENNINE
Middle Name:MARIE
Last Name:BUISHAS SIDLER
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:733 SPRUCE RD
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-1039
Mailing Address - Country:US
Mailing Address - Phone:815-464-9734
Mailing Address - Fax:815-464-9735
Practice Address - Street 1:733 SPRUCE ROAD
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-1039
Practice Address - Country:US
Practice Address - Phone:815-464-9734
Practice Address - Fax:815-464-9735
Is Sole Proprietor?:No
Enumeration Date:2009-06-02
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164001660133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric