Provider Demographics
NPI:1518664036
Name:NUSSBAUM, MICHELLE (MS, RDN, CDCES)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:NUSSBAUM
Suffix:
Gender:F
Credentials:MS, RDN, CDCES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1713 W JULIAN ST APT 3F
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-7920
Mailing Address - Country:US
Mailing Address - Phone:847-530-2853
Mailing Address - Fax:
Practice Address - Street 1:1713 W JULIAN ST APT 3F
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-7920
Practice Address - Country:US
Practice Address - Phone:847-530-2853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-15
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.007405133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered