Provider Demographics
NPI:1417436767
Name:CONDON, MARY (RD, LDN)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:CONDON
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 1:19550 GOVERNORS HWY STE 2400
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-2144
Mailing Address - Country:US
Mailing Address - Phone:708-915-8850
Mailing Address - Fax:708-915-8586
Practice Address - Street 1:19550 GOVERNORS HWY STE 2400
Practice Address - Street 2:
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-2144
Practice Address - Country:US
Practice Address - Phone:708-915-8850
Practice Address - Fax:708-915-8586
Is Sole Proprietor?:No
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164006369133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered