MEDICARE: MRS. MARYSE BEAUDOUIN DEROSENA BS MHA LDN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian		IL

General Provider Information

NPI Number	:	1285740324
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARYSE BEAUDOUIN DEROSENA BS MHA LDN

Provider Business Mailing Address
First Line	:	2405 ESSINGTON RD
Second Line	:	SUITE # 80
City	:	JOLIET
State	:	IL
Zip	:	60435-1200
Country	:	US
Telephone Number	:	815-236-6441
Fax Number	:	630-293-2937

Provider Business Practice Location Address
First Line	:	2405 ESSINGTON RD
Second Line	:	SUITE # 80
City	:	JOLIET
State	:	IL
Zip	:	60435-1200
Country	:	US
Telephone Number	:	815-236-6441
Fax Number	:	630-293-2937

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2006
Last Update Date	:	07/08/2007

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