Provider Demographics
NPI:1578039806
Name:FOX, MINDY (MS, RD, CDN)
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:
Last Name:FOX
Suffix:
Gender:F
Credentials:MS, RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2952 W BIRCHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-1220
Mailing Address - Country:US
Mailing Address - Phone:847-858-0854
Mailing Address - Fax:
Practice Address - Street 1:1225 44TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-2080
Practice Address - Country:US
Practice Address - Phone:347-746-0453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-13
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009639-1133V00000X
86084762133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered