Provider Demographics
NPI:1790507788
Name:MUKMINEVA, ELINA
Entity type:Individual
Prefix:
First Name:ELINA
Middle Name:
Last Name:MUKMINEVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2623 N HAMPDEN CT APT 3C
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-7966
Mailing Address - Country:US
Mailing Address - Phone:786-300-8001
Mailing Address - Fax:
Practice Address - Street 1:1544 W CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-5236
Practice Address - Country:US
Practice Address - Phone:773-232-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.008713133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered