Provider Demographics
NPI:1841337086
Name:MARIE, VICKIE (MA, RD, LDN)
Entity type:Individual
Prefix:
First Name:VICKIE
Middle Name:
Last Name:MARIE
Suffix:
Gender:F
Credentials:MA, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10553 S CALUMET AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-2836
Mailing Address - Country:US
Mailing Address - Phone:773-264-2687
Mailing Address - Fax:773-264-2687
Practice Address - Street 1:10553 S CALUMET AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-2836
Practice Address - Country:US
Practice Address - Phone:773-264-2687
Practice Address - Fax:773-264-2687
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164003006133V00000X
IN37001171A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001633301OtherBLUE CROSS BLUE SHIELD
MO000081657Medicare ID - Type Unspecified
IL200459Medicare ID - Type Unspecified