Provider Demographics
NPI:1659423184
Name:QUEEN, DEBRA RENEE (RD)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:RENEE
Last Name:QUEEN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:
Other - Last Name:FOUT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:109 CALIFORNIA ST
Mailing Address - Street 2:PO BOX 577
Mailing Address - City:CARTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62918
Mailing Address - Country:US
Mailing Address - Phone:618-519-9200
Mailing Address - Fax:
Practice Address - Street 1:400 S LEWIS LN
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-3547
Practice Address - Country:US
Practice Address - Phone:618-519-9200
Practice Address - Fax:618-519-9961
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1025133V00000X
IL164.006191133V00000X
OKLD718133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered