Provider Demographics
NPI:1740200732
Name:WALL, ELIZABETH A (RD)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:A
Last Name:WALL
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 1:911 SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-5432
Mailing Address - Country:US
Mailing Address - Phone:773-834-2876
Mailing Address - Fax:773-702-6972
Practice Address - Street 1:5847 S. MARYLAND AVE
Practice Address - Street 2:MC 4080
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637
Practice Address - Country:US
Practice Address - Phone:773-834-2876
Practice Address - Fax:773-702-6972
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered