Provider Demographics
NPI:1548641368
Name:WILLETTS, MIRANDA LYNN (RD, LDN, PN2)
Entity type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:LYNN
Last Name:WILLETTS
Suffix:
Gender:F
Credentials:RD, LDN, PN2
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 N KEDZIE AVE # 1N
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-3753
Mailing Address - Country:US
Mailing Address - Phone:937-470-5235
Mailing Address - Fax:
Practice Address - Street 1:2040 N KEDZIE AVE # 1N
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-3753
Practice Address - Country:US
Practice Address - Phone:937-470-5235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-17
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.005954133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered