MEDICARE: ERIKA KIMBERLY SIESENNOP RD, 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	164.004792	IL

General Provider Information

NPI Number	:	1386065654
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIKA KIMBERLY SIESENNOP RD, LDN

Provider Business Mailing Address
First Line	:	2600 W LOGAN BLVD
Second Line	:	APT 2K
City	:	CHICAGO
State	:	IL
Zip	:	60647-1888
Country	:	US
Telephone Number	:	773-241-1747
Fax Number	:

Provider Business Practice Location Address
First Line	:	561 W DIVERSEY PKWY
Second Line	:	SUITE 219
City	:	CHICAGO
State	:	IL
Zip	:	60614-6068
Country	:	US
Telephone Number	:	773-241-1747
Fax Number	:

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

Provider Enumeration Date	:	01/03/2014
Last Update Date	:	01/03/2014

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