Provider Demographics
NPI:1649800053
Name:PANOZZO, LIDIA ANTOINETTE (RD)
Entity type:Individual
Prefix:
First Name:LIDIA
Middle Name:ANTOINETTE
Last Name:PANOZZO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 W JACKSON BLVD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60661-5606
Mailing Address - Country:US
Mailing Address - Phone:312-648-4666
Mailing Address - Fax:312-648-0155
Practice Address - Street 1:10 S CLINTON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60661-3400
Practice Address - Country:US
Practice Address - Phone:312-902-2040
Practice Address - Fax:312-648-0155
Is Sole Proprietor?:No
Enumeration Date:2020-01-24
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164007631133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered