Provider Demographics
NPI:1780856526
Name:RETELNY, VICTORIA SHANTA (RD, LD)
Entity Type:Individual
Prefix:MS
First Name:VICTORIA
Middle Name:SHANTA
Last Name:RETELNY
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3024 N HAMILTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-8112
Mailing Address - Country:US
Mailing Address - Phone:773-551-9882
Mailing Address - Fax:
Practice Address - Street 1:3020 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-4208
Practice Address - Country:US
Practice Address - Phone:773-551-9882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-01
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133N00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist