Healthcare Provider Details

I. General information

NPI: 1548203763
Provider Name (Legal Business Name): TINA ANN CLONEY RD, LDN, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 CURTIS RD
CHAMPAIGN IL
61822-9678
US

IV. Provider business mailing address

611 W PARK ST
URBANA IL
61801-2501
US

V. Phone/Fax

Practice location:
  • Phone: 217-365-2853
  • Fax: 217-365-2854
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164001475
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: