Provider Demographics
NPI:1740212638
Name:DE ROUSH, JULIE A (RD)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:A
Last Name:DE ROUSH
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 1:5666 EAST STATE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2472
Mailing Address - Country:US
Mailing Address - Phone:815-226-2000
Mailing Address - Fax:815-381-7526
Practice Address - Street 1:5666 EAST STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2472
Practice Address - Country:US
Practice Address - Phone:815-226-2000
Practice Address - Fax:815-381-7526
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
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
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK26792Medicare ID - Type Unspecified