Provider Demographics
NPI:1306160155
Name:WAKEFIELD, WENDY SUE (DIETICIAN)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:SUE
Last Name:WAKEFIELD
Suffix:
Gender:F
Credentials:DIETICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2169 MARYLAND LINE RD
Mailing Address - Street 2:
Mailing Address - City:BRUCETON MILLS
Mailing Address - State:WV
Mailing Address - Zip Code:26525-6223
Mailing Address - Country:US
Mailing Address - Phone:301-533-4010
Mailing Address - Fax:301-533-4208
Practice Address - Street 1:251 N 4TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:MD
Practice Address - Zip Code:21550-1375
Practice Address - Country:US
Practice Address - Phone:301-533-4010
Practice Address - Fax:301-533-4208
Is Sole Proprietor?:No
Enumeration Date:2010-03-23
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD11002133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered