Healthcare Provider Details

I. General information

NPI: 1053742072
Provider Name (Legal Business Name): MRS. MARY DYSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2013
Last Update Date: 12/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8431 S SEELEY AVE
CHICAGO IL
60620-6035
US

IV. Provider business mailing address

8431 S SEELEY AVE
CHICAGO IL
60620-6035
US

V. Phone/Fax

Practice location:
  • Phone: 773-236-1336
  • Fax:
Mailing address:
  • Phone: 773-236-1336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number164002685
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: