Provider Demographics
NPI:1154623742
Name:GAINES, PATRICIA ANN (RD, LDN)
Entity type:Individual
Prefix:MISS
First Name:PATRICIA
Middle Name:ANN
Last Name:GAINES
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 1:9600 GROSS POINT ROAD.
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60016-1752
Mailing Address - Country:US
Mailing Address - Phone:847-933-6802
Mailing Address - Fax:847-933-6807
Practice Address - Street 1:9600 GROSS POINT ROAD.
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60016-1752
Practice Address - Country:US
Practice Address - Phone:847-933-6802
Practice Address - Fax:847-933-6807
Is Sole Proprietor?:No
Enumeration Date:2010-12-02
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.001196133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL98390OtherMEDICARE PART B
ILL98390OtherMEDICARE PART B