Provider Demographics
NPI:1962977421
Name:FISHER, ASHLEY (RD LDN)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:FISHER
Suffix:
Gender:F
Credentials:RD LDN
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:
Other - Last Name:WIDOMSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD LDN
Mailing Address - Street 1:5651 W AINSLIE ST UNIT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-2011
Mailing Address - Country:US
Mailing Address - Phone:847-361-5809
Mailing Address - Fax:
Practice Address - Street 1:5645 W ADDISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-4403
Practice Address - Country:US
Practice Address - Phone:773-282-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-10
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.007418133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered