Provider Demographics
NPI:1861701500
Name:PALUMBO, NICHOLAS S (RD)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:S
Last Name:PALUMBO
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2003 W FULTON ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-2345
Mailing Address - Country:US
Mailing Address - Phone:312-850-3438
Mailing Address - Fax:312-638-9872
Practice Address - Street 1:2003 W FULTON ST
Practice Address - Street 2:SUITE 105
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-2345
Practice Address - Country:US
Practice Address - Phone:312-850-3438
Practice Address - Fax:312-638-9872
Is Sole Proprietor?:No
Enumeration Date:2010-09-29
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164005341133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL248002576OtherLICENSE
IL164005341OtherLICENSE