Provider Demographics
NPI:1790081594
Name:BURNS, CHERYL L (RD)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:L
Last Name:BURNS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:CHERYL
Other - Middle Name:L
Other - Last Name:GRESL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 19654
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9654
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-545-1229
Practice Address - Street 1:751 N RUTLEDGE ST STE 300
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4968
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-545-1229
Is Sole Proprietor?:No
Enumeration Date:2011-01-27
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164-000220133V00000X, 133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL256510092Medicare PIN