Healthcare Provider Details

I. General information

NPI: 1730556804
Provider Name (Legal Business Name): MOLLY DEPRENGER MS, RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2015
Last Update Date: 08/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 W HARRISON ST
CHICAGO IL
60612-3841
US

IV. Provider business mailing address

1725 W HARRISON ST
CHICAGO IL
60612-3841
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-4444
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.006518
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: