Provider Demographics
NPI:1588088777
Name:RILEY, STEFANIE (RD)
Entity type:Individual
Prefix:
First Name:STEFANIE
Middle Name:
Last Name:RILEY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:STEFANIE
Other - Middle Name:
Other - Last Name:DJURIC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:2717 CLEARVIEW DRIVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52601
Mailing Address - Country:US
Mailing Address - Phone:815-519-2891
Mailing Address - Fax:
Practice Address - Street 1:1975 NATIONAL BLVD
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-1488
Practice Address - Country:US
Practice Address - Phone:309-344-1100
Practice Address - Fax:309-344-1204
Is Sole Proprietor?:No
Enumeration Date:2014-02-10
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164005775133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered