Provider Demographics
NPI:1851512982
Name:BALISTER, WENDY S (RD)
Entity type:Individual
Prefix:MRS
First Name:WENDY
Middle Name:S
Last Name:BALISTER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W156N6406 WILDFLOWER DRIVE
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051
Mailing Address - Country:US
Mailing Address - Phone:262-703-0009
Mailing Address - Fax:
Practice Address - Street 1:13111 NORTH PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WV
Practice Address - Zip Code:53097
Practice Address - Country:US
Practice Address - Phone:262-243-7376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI727508133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered