Healthcare Provider Details

I. General information

NPI: 1881938124
Provider Name (Legal Business Name): STEPHANIE CIUCCI RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/26/2012
Last Update Date: 11/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3080 OGDEN AVE 104
LISLE IL
60532-1691
US

IV. Provider business mailing address

3080 OGDEN AVE 104
LISLE IL
60532-1691
US

V. Phone/Fax

Practice location:
  • Phone: 630-839-9296
  • Fax: 630-364-1873
Mailing address:
  • Phone: 630-839-9296
  • Fax: 630-364-1873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.004548
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: