Provider Demographics
NPI:1073336798
Name:WAWRZON, LILY BETH (RD, LDN)
Entity type:Individual
Prefix:MISS
First Name:LILY
Middle Name:BETH
Last Name:WAWRZON
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:965 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1292
Mailing Address - Country:US
Mailing Address - Phone:708-902-4522
Mailing Address - Fax:
Practice Address - Street 1:965 LAKE ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1292
Practice Address - Country:US
Practice Address - Phone:708-902-4522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-01
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.011098133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered