Healthcare Provider Details

I. General information

NPI: 1710248448
Provider Name (Legal Business Name): AMI DIANE FROESE RD LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2012
Last Update Date: 05/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 BROADWAY ST
QUINCY IL
62301-2834
US

IV. Provider business mailing address

1309 SPRING ST
QUINCY IL
62301-2845
US

V. Phone/Fax

Practice location:
  • Phone: 217-223-8400
  • Fax: 217-223-9716
Mailing address:
  • Phone: 217-617-7973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number164005500
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: