Provider Demographics
NPI:1215641063
Name:ROSS, ALEXA RAE (MS, RDN, LDN)
Entity type:Individual
Prefix:
First Name:ALEXA
Middle Name:RAE
Last Name:ROSS
Suffix:
Gender:F
Credentials:MS, RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 ELMWOOD AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-4956
Mailing Address - Country:US
Mailing Address - Phone:734-474-7123
Mailing Address - Fax:
Practice Address - Street 1:904 ELMWOOD AVE APT 2
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-4956
Practice Address - Country:US
Practice Address - Phone:734-474-7123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-06
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164008000133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered