Provider Demographics
NPI:1063533602
Name:WYNN, ILENE TERRI (RD, LDN)
Entity type:Individual
Prefix:MRS
First Name:ILENE
Middle Name:TERRI
Last Name:WYNN
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2246 AVALON DR
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-4682
Mailing Address - Country:US
Mailing Address - Phone:847-913-1652
Mailing Address - Fax:847-913-1758
Practice Address - Street 1:1560 SHERMAN AVE
Practice Address - Street 2:SUITE #400
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4818
Practice Address - Country:US
Practice Address - Phone:847-869-1500
Practice Address - Fax:847-869-1515
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered