Provider Demographics
NPI:1215064449
Name:MCCLINTOCK, WENDOLYN E (RD, LD)
Entity type:Individual
Prefix:
First Name:WENDOLYN
Middle Name:E
Last Name:MCCLINTOCK
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1226
Mailing Address - Street 2:
Mailing Address - City:BONNERS FERRY
Mailing Address - State:ID
Mailing Address - Zip Code:83805-1226
Mailing Address - Country:US
Mailing Address - Phone:208-267-2570
Mailing Address - Fax:
Practice Address - Street 1:COUNTY ROAD 62 C
Practice Address - Street 2:
Practice Address - City:BONNERS FERRY
Practice Address - State:ID
Practice Address - Zip Code:83805-1226
Practice Address - Country:US
Practice Address - Phone:208-267-2570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-182133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered