Provider Demographics
NPI:1760238299
Name:CLESEN, COLLEEN (NDTR)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:CLESEN
Suffix:
Gender:F
Credentials:NDTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 ASH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-4120
Mailing Address - Country:US
Mailing Address - Phone:630-479-2086
Mailing Address - Fax:
Practice Address - Street 1:14 N ISLAND AVE
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:IL
Practice Address - Zip Code:60510-1929
Practice Address - Country:US
Practice Address - Phone:630-479-2086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-25
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL86081341136A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered