Provider Demographics
NPI:1003459199
Name:MACHETTA, CONNIE LYNN (RDN, LDN)
Entity type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:LYNN
Last Name:MACHETTA
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 SILVER CROSS BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-9509
Mailing Address - Country:US
Mailing Address - Phone:815-300-1078
Mailing Address - Fax:815-300-2076
Practice Address - Street 1:1900 SILVER CROSS BLVD
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-9509
Practice Address - Country:US
Practice Address - Phone:815-474-0458
Practice Address - Fax:815-300-2706
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-22
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164000596133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered