Provider Demographics
NPI:1760787378
Name:PHILLIPS, SANDRA MARIE (LDN)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:MARIE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2262 W. 119TH PL.
Mailing Address - Street 2:2262 W. 119THPL
Mailing Address - City:BLUE ISLAND
Mailing Address - State:IN
Mailing Address - Zip Code:60406-1123
Mailing Address - Country:US
Mailing Address - Phone:630-865-2529
Mailing Address - Fax:708-385-0882
Practice Address - Street 1:2262 W. 119TH PL.
Practice Address - Street 2:
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-1123
Practice Address - Country:US
Practice Address - Phone:630-865-2529
Practice Address - Fax:708-385-0882
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-13
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.003956133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education