Healthcare Provider Details

I. General information

NPI: 1063962603
Provider Name (Legal Business Name): ALEXANDRA OTWELL MS, RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2016
Last Update Date: 10/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5962 N ELSTON AVE
CHICAGO IL
60646-5540
US

IV. Provider business mailing address

2300 N LINCOLN PARK W APT 416
CHICAGO IL
60614-3252
US

V. Phone/Fax

Practice location:
  • Phone: 773-774-2470
  • Fax:
Mailing address:
  • Phone: 815-218-8470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.006655
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: