Provider Demographics
NPI:1003188392
Name:CLERKIN, RENEE ANN (RD)
Entity type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:ANN
Last Name:CLERKIN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MRS
Other - First Name:RENEE
Other - Middle Name:ANN
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:2300 W WABANSIA AVE
Mailing Address - Street 2:UNIT 214
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-5338
Mailing Address - Country:US
Mailing Address - Phone:317-442-5134
Mailing Address - Fax:
Practice Address - Street 1:2300 W WABANSIA AVE
Practice Address - Street 2:UNIT 214
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-5338
Practice Address - Country:US
Practice Address - Phone:317-442-5134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-01
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.005048133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered