Healthcare Provider Details

I. General information

NPI: 1548873938
Provider Name (Legal Business Name): AUDRA LEIGH CISNA RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2020
Last Update Date: 08/26/2020
Certification Date: 08/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 W PARK ST
URBANA IL
61801-2334
US

IV. Provider business mailing address

14 NIGHTINGALE CIR
CAMARGO IL
61919-3504
US

V. Phone/Fax

Practice location:
  • Phone: 217-337-2890
  • Fax:
Mailing address:
  • Phone: 217-714-4708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164004975
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: