Provider Demographics
NPI:1811424948
Name:CONNEELY, EILEEN (RD,LD, CPT)
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:
Last Name:CONNEELY
Suffix:
Gender:F
Credentials:RD,LD, CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17612 MULBERRY AVE
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60487-7694
Mailing Address - Country:US
Mailing Address - Phone:773-771-4655
Mailing Address - Fax:
Practice Address - Street 1:14711 S RAVINIA AVE
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-3100
Practice Address - Country:US
Practice Address - Phone:708-226-0555
Practice Address - Fax:708-226-0555
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-19
Last Update Date:2017-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1033430133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1033430OtherCOMMISSION ON DIETETIC REGISTRATION