Provider Demographics
NPI:1649866393
Name:MUMPHERY, AUDRIE L (MS, RDN, LDN, CFPM)
Entity type:Individual
Prefix:MS
First Name:AUDRIE
Middle Name:L
Last Name:MUMPHERY
Suffix:
Gender:F
Credentials:MS, RDN, LDN, CFPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2249 W 115TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-4701
Mailing Address - Country:US
Mailing Address - Phone:773-550-9788
Mailing Address - Fax:
Practice Address - Street 1:2249 W 115TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-4701
Practice Address - Country:US
Practice Address - Phone:773-550-9788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.008136133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered