Healthcare Provider Details

I. General information

NPI: 1962435263
Provider Name (Legal Business Name): EMILY NICOLE LISCIANDRO MS, RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVE MC0988
CHICAGO IL
60637-1447
US

IV. Provider business mailing address

16717 GENTRY LN #201
TINLEY PARK IL
60477-7107
US

V. Phone/Fax

Practice location:
  • Phone: 773-702-0551
  • Fax:
Mailing address:
  • Phone: 312-636-9604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: