Healthcare Provider Details

I. General information

NPI: 1003673856
Provider Name (Legal Business Name): DIANA THUY KHANH HOANG RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2024
Last Update Date: 02/28/2024
Certification Date: 02/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2653 W OGDEN AVE
CHICAGO IL
60608-1647
US

IV. Provider business mailing address

26374 WOODLINE CT
FLAT ROCK MI
48134-1864
US

V. Phone/Fax

Practice location:
  • Phone: 773-257-6508
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.009466
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: