Provider Demographics
NPI:1538550132
Name:THOMAS, STEPHANIE LYNN (RD, CD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYNN
Last Name:THOMAS
Suffix:
Gender:F
Credentials:RD, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 ELGIN CT
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61571-1143
Mailing Address - Country:US
Mailing Address - Phone:219-241-0234
Mailing Address - Fax:
Practice Address - Street 1:530 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637-3201
Practice Address - Country:US
Practice Address - Phone:309-624-9844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-18
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164009191133V00000X
IN37002483A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ININ3131008OtherMEDICARE PTAN