Provider Demographics
NPI:1952704504
Name:ILLG, HEATHER SUE (RD LD)
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:SUE
Last Name:ILLG
Suffix:
Gender:F
Credentials:RD LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8701 DOUGLAS AVE
Mailing Address - Street 2:
Mailing Address - City:URBANDALE
Mailing Address - State:IA
Mailing Address - Zip Code:50322-2200
Mailing Address - Country:US
Mailing Address - Phone:515-251-5284
Mailing Address - Fax:515-270-2227
Practice Address - Street 1:8701 DOUGLAS AVE
Practice Address - Street 2:
Practice Address - City:URBANDALE
Practice Address - State:IA
Practice Address - Zip Code:50322-2200
Practice Address - Country:US
Practice Address - Phone:515-251-5284
Practice Address - Fax:515-270-2227
Is Sole Proprietor?:No
Enumeration Date:2014-09-26
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01342136A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered