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General NPI Number Information
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NPI Number | 1992404958
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Entity Type | Individual
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Provider Name | ALEXANDRA N LUNDQUIST RD
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Gender | Female
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Dates
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Enumeration Date | 02/28/2023
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Last Update Date | 10/13/2023
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Provider Practice Location Address
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Address Line | 328 N NEIL ST STE C
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City | CHAMPAIGN
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State | IL
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Zip | 61820-3614
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Country | US
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Telephone | 217-377-0299
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Fax |
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Provider Business Mailing Address
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Address Line | 1512 W GREEN ST
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City | CHAMPAIGN
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State | IL
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Zip | 61821-3724
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Country | US
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Telephone | 217-621-8736
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | 164009058
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License Number State | IL
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