Provider Demographics
NPI:1003214222
Name:GORDON, WENDY LYNN (RD, RDH)
Entity Type:Individual
Prefix:MRS
First Name:WENDY
Middle Name:LYNN
Last Name:GORDON
Suffix:
Gender:F
Credentials:RD, RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-4542
Mailing Address - Country:US
Mailing Address - Phone:218-844-7161
Mailing Address - Fax:
Practice Address - Street 1:1415 MADISON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-4542
Practice Address - Country:US
Practice Address - Phone:218-844-7161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-22
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2886133V00000X
ND839133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered