Healthcare Provider Details

I. General information

NPI: 1245566637
Provider Name (Legal Business Name): CYNTHIA R LESSEN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2009
Last Update Date: 10/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1418 COLLEGE DR
MOUNT CARMEL IL
62863-2638
US

IV. Provider business mailing address

435 CAMPUS VIEW DR
LINCOLN IL
62656-2101
US

V. Phone/Fax

Practice location:
  • Phone: 618-262-8621
  • Fax: 618-263-6467
Mailing address:
  • Phone: 618-262-8621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164002225
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: