Healthcare Provider Details

I. General information

NPI: 1396142691
Provider Name (Legal Business Name): MARSHA CYNDI CANSLER RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2014
Last Update Date: 12/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2708 CHARIOT LN
OLYMPIA FIELDS IL
60461-1515
US

IV. Provider business mailing address

2708 CHARIOT LN
OLYMPIA FIELDS IL
60461-1515
US

V. Phone/Fax

Practice location:
  • Phone: 708-712-2743
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.006350
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: