Provider Demographics
NPI:1861883407
Name:ARNOLD, WENDY
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:ARNOLD
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 1:2614 W JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-6433
Mailing Address - Country:US
Mailing Address - Phone:815-725-1355
Mailing Address - Fax:815-725-9867
Practice Address - Street 1:2614 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-6433
Practice Address - Country:US
Practice Address - Phone:815-725-1355
Practice Address - Fax:815-725-9867
Is Sole Proprietor?:No
Enumeration Date:2015-02-17
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.003490133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1952498628Medicare PIN