Provider Demographics
NPI:1992095459
Name:NYGREN, SCOTT MICHAEL (RD, LND)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:MICHAEL
Last Name:NYGREN
Suffix:
Gender:M
Credentials:RD, LND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2043 IRONWOOD CT
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-1795
Mailing Address - Country:US
Mailing Address - Phone:847-263-0617
Mailing Address - Fax:
Practice Address - Street 1:3001 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:NORTH CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60064-3048
Practice Address - Country:US
Practice Address - Phone:224-610-5330
Practice Address - Fax:224-610-3847
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-18
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164000288133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered