Healthcare Provider Details

I. General information

NPI: 1881107787
Provider Name (Legal Business Name): LAUREN GUSTAFSON MS, RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2017
Last Update Date: 11/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3249 OAK PARK AVE
BERWYN IL
60402-3429
US

IV. Provider business mailing address

514 OAKTON ST
ELK GROVE VILLAGE IL
60007-1729
US

V. Phone/Fax

Practice location:
  • Phone: 708-783-3077
  • Fax:
Mailing address:
  • Phone: 224-558-3892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164007182
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: