Individual
VICKIE MARIE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MA, RD, LDN
Contact information
Practice address
10553 S CALUMET AVE, CHICAGO, IL 60628-2836
(773) 264-2687
(773) 264-2687
Mailing address
10553 S CALUMET AVE, CHICAGO, IL 60628-2836
(773) 264-2687
(773) 264-2687
Taxonomy
Speciality
Code
Description
License number
State
133V00000X
Registered Dietitian
Primary
164003006
IL
133V00000X
Registered Dietitian
37001171A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0001633301
BLUE CROSS BLUE SHIELD
IL
Enumeration date
01/30/2007
Last updated
12/29/2010
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