Provider Demographics
NPI:1598372252
Name:EGAN, NORA P
Entity Type:Individual
Prefix:
First Name:NORA
Middle Name:P
Last Name:EGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2266 W 109TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-3212
Mailing Address - Country:US
Mailing Address - Phone:773-972-9130
Mailing Address - Fax:
Practice Address - Street 1:2266 W 109TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-3212
Practice Address - Country:US
Practice Address - Phone:773-972-9130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164008155133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered