Provider Demographics
NPI:1518338367
Name:MANISCO, JUDY ESTELLE (RD, LDN)
Entity Type:Individual
Prefix:MRS
First Name:JUDY
Middle Name:ESTELLE
Last Name:MANISCO
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 1:40 PRAIRIE PARK DR
Mailing Address - Street 2:# 305
Mailing Address - City:WHEELING
Mailing Address - State:IL
Mailing Address - Zip Code:60090-2725
Mailing Address - Country:US
Mailing Address - Phone:708-257-5541
Mailing Address - Fax:
Practice Address - Street 1:40 PRAIRIE PARK DR
Practice Address - Street 2:# 305
Practice Address - City:WHEELING
Practice Address - State:IL
Practice Address - Zip Code:60090-2725
Practice Address - Country:US
Practice Address - Phone:708-257-5541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-19
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1640013123133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered