Provider Demographics
NPI:1992110027
Name:VENKAT, SOWMYA (MS RD LDN)
Entity type:Individual
Prefix:
First Name:SOWMYA
Middle Name:
Last Name:VENKAT
Suffix:
Gender:F
Credentials:MS RD LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:267 BISCAYNE ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-3309
Mailing Address - Country:US
Mailing Address - Phone:630-258-1079
Mailing Address - Fax:
Practice Address - Street 1:267 BISCAYNE ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-3309
Practice Address - Country:US
Practice Address - Phone:630-258-1079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-26
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.006082133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered