Healthcare Provider Details

I. General information

NPI: 1952024952
Provider Name (Legal Business Name): AMANDA R LARREA RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA R SEVERSON RD

II. Dates (important events)

Enumeration Date: 09/23/2022
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12004 S ROUTE 59 UNIT 100
PLAINFIELD IL
60585-5108
US

IV. Provider business mailing address

PO BOX 713260
CHICAGO IL
60677-1260
US

V. Phone/Fax

Practice location:
  • Phone: 630-364-7850
  • Fax: 630-432-6604
Mailing address:
  • Phone: 630-469-9200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164-009042
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: