Provider Demographics
NPI:1750590311
Name:SAMPLE, GLORIA (RD)
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:
Last Name:SAMPLE
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 1:411 FAYETTE DR
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543-7719
Mailing Address - Country:US
Mailing Address - Phone:630-551-0164
Mailing Address - Fax:
Practice Address - Street 1:411 FAYETTE DR
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543-7719
Practice Address - Country:US
Practice Address - Phone:630-551-0164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered