Healthcare Provider Details

I. General information

NPI: 1962223065
Provider Name (Legal Business Name): KATHLEEN ANTOINETTE ZECHMAN RD
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2024
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 WARRENVILLE RD STE 210
LISLE IL
60532-1376
US

IV. Provider business mailing address

953 LAKE RD
WELLSBORO PA
16901-7170
US

V. Phone/Fax

Practice location:
  • Phone: 312-664-3456
  • Fax:
Mailing address:
  • Phone: 570-948-1259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86102985
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: