Provider Demographics
NPI:1548873938
Name:CISNA, AUDRA LEIGH (RDN)
Entity type:Individual
Prefix:
First Name:AUDRA
Middle Name:LEIGH
Last Name:CISNA
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 NIGHTINGALE CIR
Mailing Address - Street 2:
Mailing Address - City:CAMARGO
Mailing Address - State:IL
Mailing Address - Zip Code:61919-3504
Mailing Address - Country:US
Mailing Address - Phone:217-714-4708
Mailing Address - Fax:
Practice Address - Street 1:1400 W PARK ST
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2334
Practice Address - Country:US
Practice Address - Phone:217-337-2890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164004975133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered