Provider Demographics
NPI:1275857138
Name:GANNON, TRULY
Entity type:Individual
Prefix:
First Name:TRULY
Middle Name:
Last Name:GANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TRULY
Other - Middle Name:
Other - Last Name:NORMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3860 W OGDEN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60623-2460
Mailing Address - Country:US
Mailing Address - Phone:773-843-3000
Mailing Address - Fax:773-843-2704
Practice Address - Street 1:3860 W OGDEN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-2460
Practice Address - Country:US
Practice Address - Phone:773-843-3000
Practice Address - Fax:773-843-2704
Is Sole Proprietor?:No
Enumeration Date:2010-03-22
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164005059133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered