Healthcare Provider Details

I. General information

NPI: 1154378826
Provider Name (Legal Business Name): JULIE R DOSTAL RD,CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 12/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 E WASHINGTON ST STE 300C
BLOOMINGTON IL
61704-4480
US

IV. Provider business mailing address

2401 E WASHINGTON ST # 300C
BLOOMINGTON IL
61704-4480
US

V. Phone/Fax

Practice location:
  • Phone: 309-830-0711
  • Fax: 866-592-3004
Mailing address:
  • Phone: 309-830-0711
  • Fax: 309-663-2310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.001279
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: