Healthcare Provider Details

I. General information

NPI: 1558273631
Provider Name (Legal Business Name): CLARISSA THANNEN RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 N RUTLEDGE ST STE 1700
SPRINGFIELD IL
62702-4968
US

IV. Provider business mailing address

751 N RUTLEDGE ST STE 1700
SPRINGFIELD IL
62702-4968
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8000
  • Fax:
Mailing address:
  • Phone: 217-545-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164025792
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: