Provider Demographics
NPI:1720407000
Name:REILLY, DIANE (RD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:REILLY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 ORLAND SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-3206
Mailing Address - Country:US
Mailing Address - Phone:708-873-5965
Mailing Address - Fax:
Practice Address - Street 1:29 ORLAND SQUARE DR
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-3206
Practice Address - Country:US
Practice Address - Phone:708-873-5965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-15
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.000266133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered