Healthcare Provider Details

I. General information

NPI: 1982720215
Provider Name (Legal Business Name): MARLENE S. CUPP RD,LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 06/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

733 SPRUCE RD
FRANKFORT IL
60423-1039
US

IV. Provider business mailing address

733 SPRUCE RD
FRANKFORT IL
60423-1039
US

V. Phone/Fax

Practice location:
  • Phone: 815-464-9734
  • Fax: 815-464-9735
Mailing address:
  • Phone: 815-464-9734
  • Fax: 815-464-9735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: