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 1:2222 WELBORN ST
Mailing Address - Street 2:DIETARY DEPARTMENT
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-3924
Mailing Address - Country:US
Mailing Address - Phone:214-559-7534
Mailing Address - Fax:214-559-8394
Practice Address - Street 1:2222 WELBORN ST
Practice Address - Street 2:DIETARY DEPARTMENT
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-3924
Practice Address - Country:US
Practice Address - Phone:214-559-7534
Practice Address - Fax:214-559-8394
Is Sole Proprietor?:No
Enumeration Date:2015-07-16
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
TXDT05780133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered