Provider Demographics
NPI:1427432731
Name:WITTENBROOK, GWENDOLYN ANN (MA, RD, CSP, LD)
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:ANN
Last Name:WITTENBROOK
Suffix:
Gender:F
Credentials:MA, RD, CSP, LD
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:
Other - Last Name:WITTENBROOK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, RD, CSP, LD
Mailing Address - Street 1:12606 GREENVILLE AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-1923
Mailing Address - Country:US
Mailing Address - Phone:469-780-4590
Mailing Address - Fax:972-437-1988
Practice Address - Street 1:12606 GREENVILLE AVE STE 200
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-1923
Practice Address - Country:US
Practice Address - Phone:469-780-4590
Practice Address - Fax:972-437-1988
Is Sole Proprietor?:No
Enumeration Date:2015-07-16
Last Update Date:2025-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT05870133V00000X
TXDT05780133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric