Provider Demographics
NPI:1336305374
Name:WALLER, REBECCA ANNE (RD)
Entity type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:ANNE
Last Name:WALLER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 W HIGHWAY 22
Mailing Address - Street 2:FOOD AND NUTRITION
Mailing Address - City:BARRINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60010-1919
Mailing Address - Country:US
Mailing Address - Phone:847-381-9600
Mailing Address - Fax:
Practice Address - Street 1:450 W HIGHWAY 22
Practice Address - Street 2:FOOD AND NUTRITION
Practice Address - City:BARRINGTON
Practice Address - State:IL
Practice Address - Zip Code:60010-1919
Practice Address - Country:US
Practice Address - Phone:847-381-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-30
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL923591133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered