Provider Demographics
NPI:1053593673
Name:BROWN-SANDUSKY, JUDETH A (CN)
Entity type:Individual
Prefix:
First Name:JUDETH
Middle Name:A
Last Name:BROWN-SANDUSKY
Suffix:
Gender:F
Credentials:CN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 TYLER CREEK PLZ
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-1784
Mailing Address - Country:US
Mailing Address - Phone:847-742-8225
Mailing Address - Fax:847-742-8225
Practice Address - Street 1:108 TYLER CREEK PLZ
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-1784
Practice Address - Country:US
Practice Address - Phone:847-742-8225
Practice Address - Fax:847-742-8225
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-05
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL001030133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist