Healthcare Provider Details

I. General information

NPI: 1538203062
Provider Name (Legal Business Name): JILL ELISE HICKEY RD, CDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2007
Last Update Date: 03/29/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

761 MAIN AVE STE 200
NORWALK CT
06851-1080
US

IV. Provider business mailing address

761 MAIN AVE STE 200
NORWALK CT
06851-1080
US

V. Phone/Fax

Practice location:
  • Phone: 203-750-7400
  • Fax:
Mailing address:
  • Phone: 203-750-7400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND 5374
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.004604
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number59.001450
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: