Provider Demographics
NPI:1760016075
Name:SPENCER, ELIZABETH (RD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:SPENCER
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 1:1534 N CLAREMONT AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-1781
Mailing Address - Country:US
Mailing Address - Phone:502-608-5954
Mailing Address - Fax:
Practice Address - Street 1:561 W DIVERSEY PKWY
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-6068
Practice Address - Country:US
Practice Address - Phone:312-553-1754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-25
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164007672133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA