Provider Demographics
NPI:1720418916
Name:OBRIEN, MELISSA (MS RD LDN)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:OBRIEN
Suffix:
Gender:F
Credentials:MS RD LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 E HAWTHORN PKWY STE 235
Mailing Address - Street 2:
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-1454
Mailing Address - Country:US
Mailing Address - Phone:847-737-8768
Mailing Address - Fax:847-859-5885
Practice Address - Street 1:16221 W 159TH ST STE 102
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60441
Practice Address - Country:US
Practice Address - Phone:847-868-3435
Practice Address - Fax:847-859-5885
Is Sole Proprietor?:No
Enumeration Date:2013-11-25
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164003821133V00000X
IL164.003821133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL164003821OtherSTATE OF ILLINOIS