Healthcare Provider Details

I. General information

NPI: 1083175301
Provider Name (Legal Business Name): ALLYSON COLE RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2019
Last Update Date: 09/11/2023
Certification Date: 09/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3341 W PILGRIMS WAY
PEORIA IL
61615-9512
US

IV. Provider business mailing address

3341 W PILGRIMS WAY
PEORIA IL
61615-9512
US

V. Phone/Fax

Practice location:
  • Phone: 815-685-1563
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: