Healthcare Provider Details

I. General information

NPI: 1285640904
Provider Name (Legal Business Name): ELIZABETH J WICKMAN RD,LDN,CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 S WASHINGTON ST
NAPERVILLE IL
60540-7430
US

IV. Provider business mailing address

801 S WASHINGTON ST
NAPERVILLE IL
60540-7430
US

V. Phone/Fax

Practice location:
  • Phone: 630-527-3213
  • Fax:
Mailing address:
  • Phone: 630-527-3213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: