MEDICARE: ASHLEY RYAN FAVRE RD

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	2016013025	MO
2	133V00000X	Registered Dietitian	164007798	IL

General Provider Information

NPI Number	:	1295435717
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ASHLEY RYAN FAVRE RD

Provider Business Mailing Address
First Line	:	1 TWIN OAKS DR
Second Line	:
City	:	SHILOH
State	:	IL
Zip	:	62221-4442
Country	:	US
Telephone Number	:	870-391-6865
Fax Number	:

Provider Business Practice Location Address
First Line	:	4322 MCREE AVE APT 2W
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63110-2253
Country	:	US
Telephone Number	:	870-391-6865
Fax Number	:

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

Provider Enumeration Date	:	03/03/2023
Last Update Date	:	03/03/2023

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