Provider Demographics
NPI:1043648090
Name:WENTZ, LYNNE
Entity Type:Individual
Prefix:
First Name:LYNNE
Middle Name:
Last Name:WENTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LYNNE
Other - Middle Name:
Other - Last Name:PUTNAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, BSN, MHS, CDE
Mailing Address - Street 1:23815 S RAYMOND DR
Mailing Address - Street 2:
Mailing Address - City:CRETE
Mailing Address - State:IL
Mailing Address - Zip Code:60417-1863
Mailing Address - Country:US
Mailing Address - Phone:708-275-6578
Mailing Address - Fax:708-367-0713
Practice Address - Street 1:2701 W 68TH ST
Practice Address - Street 2:RM.S 409
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-1813
Practice Address - Country:US
Practice Address - Phone:773-884-9899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-29
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.240560163WD0400X, 174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
No174H00000XOther Service ProvidersHealth Educator