Provider Demographics
NPI:1265219331
Name:COLLANTO, MADELEINE JOY (RD)
Entity type:Individual
Prefix:
First Name:MADELEINE
Middle Name:JOY
Last Name:COLLANTO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:676 N SAINT CLAIR ST STE 2025
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2927
Mailing Address - Country:US
Mailing Address - Phone:312-695-0596
Mailing Address - Fax:312-695-5232
Practice Address - Street 1:676 N SAINT CLAIR ST STE 2025
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2927
Practice Address - Country:US
Practice Address - Phone:312-695-0596
Practice Address - Fax:312-695-5232
Is Sole Proprietor?:No
Enumeration Date:2023-09-12
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164008979133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered