Provider Demographics
NPI:1396142493
Name:ANDERSON, VIVIAN RUTH (RDN, LDN)
Entity type:Individual
Prefix:MRS
First Name:VIVIAN
Middle Name:RUTH
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1445 W EDGEWATER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-4208
Mailing Address - Country:US
Mailing Address - Phone:309-660-0138
Mailing Address - Fax:
Practice Address - Street 1:1445 W EDGEWATER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-4208
Practice Address - Country:US
Practice Address - Phone:309-660-0138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-04
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164004227133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered