Provider Demographics
NPI:1972718245
Name:OH, ELENA (MS RDN LDN, CDE)
Entity Type:Individual
Prefix:MS
First Name:ELENA
Middle Name:
Last Name:OH
Suffix:
Gender:F
Credentials:MS RDN LDN, CDE
Other - Prefix:
Other - First Name:ELENA
Other - Middle Name:
Other - Last Name:STONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS RDN LDN CDE
Mailing Address - Street 1:2316 PEBBLESTONE WAY
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60490-5059
Mailing Address - Country:US
Mailing Address - Phone:401-829-6647
Mailing Address - Fax:
Practice Address - Street 1:2316 PEBBLESTONE WAY
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60490-5059
Practice Address - Country:US
Practice Address - Phone:877-443-5227
Practice Address - Fax:888-557-0978
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164005443133V00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI05-0466452OtherMULTI PLAN PROVIDER
RIHA00033Medicaid