Healthcare Provider Details

I. General information

NPI: 1487132874
Provider Name (Legal Business Name): KAREN S MISCHLER MS, RD, CLC, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2018
Last Update Date: 07/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 NE GLEN OAK AVE STE 301
PEORIA IL
61603-3169
US

IV. Provider business mailing address

420 NE GLEN OAK AVE STE 301
PEORIA IL
61603-3169
US

V. Phone/Fax

Practice location:
  • Phone: 309-655-3453
  • Fax: 309-655-3410
Mailing address:
  • Phone: 309-655-3453
  • Fax: 309-655-3410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164003819
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: