MEDICARE: HANNAH NICOLE POLK RD, LDN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	164.007663	IL

General Provider Information

NPI Number	:	1578273215
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HANNAH NICOLE POLK RD, LDN

Provider Business Mailing Address
First Line	:	12717 S AUSTIN AVE
Second Line	:
City	:	PALOS HEIGHTS
State	:	IL
Zip	:	60463-2339
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12717 S AUSTIN AVE
Second Line	:
City	:	PALOS HEIGHTS
State	:	IL
Zip	:	60463-2339
Country	:	US
Telephone Number	:	314-398-1494
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/05/2022
Last Update Date	:	12/05/2022

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