Provider Demographics
NPI:1154378826
Name:DOSTAL, JULIE R (RD,CDE)
Entity type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:R
Last Name:DOSTAL
Suffix:
Gender:F
Credentials:RD,CDE
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2401 E WASHINGTON ST
Mailing Address - Street 2:# 300C
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-4480
Mailing Address - Country:US
Mailing Address - Phone:309-830-0711
Mailing Address - Fax:309-663-2310
Practice Address - Street 1:2401 E WASHINGTON ST
Practice Address - Street 2:STE 300C
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-4480
Practice Address - Country:US
Practice Address - Phone:309-830-0711
Practice Address - Fax:866-592-3004
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-28
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL164.001279133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered