Healthcare Provider Details

I. General information

NPI: 1023319365
Provider Name (Legal Business Name): NICOLLE JEANETTE PUTNAM R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2010
Last Update Date: 11/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 5TH ST SUITE 51
SILVIS IL
61282-2903
US

IV. Provider business mailing address

321 E 7TH ST #208
DAVENPORT IA
52803-5513
US

V. Phone/Fax

Practice location:
  • Phone: 309-792-1507
  • Fax: 309-792-1518
Mailing address:
  • Phone: 515-720-9178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.005326
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: