Provider Demographics
NPI:1447907415
Name:LILLIE, MOLLIE (RD)
Entity type:Individual
Prefix:
First Name:MOLLIE
Middle Name:
Last Name:LILLIE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 S KNIGHT AVE
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-3804
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:836 W WELLINGTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5147
Practice Address - Country:US
Practice Address - Phone:773-975-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-09
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered