Provider Demographics
NPI:1952024952
Name:LARREA, AMANDA R (RD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:R
Last Name:LARREA
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:R
Other - Last Name:SEVERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:PO BOX 713260
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-1260
Mailing Address - Country:US
Mailing Address - Phone:630-469-9200
Mailing Address - Fax:
Practice Address - Street 1:12004 S ROUTE 59 UNIT 100
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60585-5108
Practice Address - Country:US
Practice Address - Phone:630-364-7850
Practice Address - Fax:630-432-6604
Is Sole Proprietor?:No
Enumeration Date:2022-09-23
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164-009042133V00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered