Healthcare Provider Details

I. General information

NPI: 1184387573
Provider Name (Legal Business Name): JAMEY A BAIETTO RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2021
Last Update Date: 10/21/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 E MADISON ST STE 1F
SPRINGFIELD IL
62701-3118
US

IV. Provider business mailing address

PO BOX 3428
SPRINGFIELD IL
62708-3428
US

V. Phone/Fax

Practice location:
  • Phone: 217-788-3948
  • Fax: 217-527-3209
Mailing address:
  • Phone: 217-588-2624
  • Fax: 217-757-7550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.007582
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: