Provider Demographics
NPI:1255610044
Name:MARSH, STEPHANIE RENEE (RD, LDN)
Entity type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:RENEE
Last Name:MARSH
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5855 N VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-4875
Mailing Address - Country:US
Mailing Address - Phone:810-923-9289
Mailing Address - Fax:
Practice Address - Street 1:701 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-1699
Practice Address - Country:US
Practice Address - Phone:708-538-4689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-10
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164005394133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL164005394Medicaid