Healthcare Provider Details

I. General information

NPI: 1982945697
Provider Name (Legal Business Name): MONICA JOYCE RD CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2013
Last Update Date: 06/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9812 S DAMEN
CHICAGO IL
60043
US

IV. Provider business mailing address

541 KINCAID ST
HIGHLAND PARK IL
60035-5035
US

V. Phone/Fax

Practice location:
  • Phone: 773-636-3353
  • Fax:
Mailing address:
  • Phone: 773-636-3353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.002111
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: