Healthcare Provider Details

I. General information

NPI: 1275725244
Provider Name (Legal Business Name): VANDANA PURI RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2007
Last Update Date: 08/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 S MICHIGAN AVE APT 3103
CHICAGO IL
60605-2521
US

IV. Provider business mailing address

1130 S MICHIGAN AVE APT 3103
CHICAGO IL
60605-2521
US

V. Phone/Fax

Practice location:
  • Phone: 312-212-6405
  • Fax:
Mailing address:
  • Phone: 312-212-6405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: