Provider Demographics
NPI:1538854674
Name:GONZALEZ, ALEXIS DAWN (RDN LDN)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:DAWN
Last Name:GONZALEZ
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 1:2427 RIDGELAND AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-2465
Mailing Address - Country:US
Mailing Address - Phone:708-745-8220
Mailing Address - Fax:
Practice Address - Street 1:2427 RIDGELAND AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-2465
Practice Address - Country:US
Practice Address - Phone:708-745-8220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-05
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164008814133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered