Provider Demographics
NPI:1083749535
Name:WANZEK, JOAN MAUREEN (LD)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:MAUREEN
Last Name:WANZEK
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9118 GREENBELT DR
Mailing Address - Street 2:
Mailing Address - City:URBANDALE
Mailing Address - State:IA
Mailing Address - Zip Code:50322-7446
Mailing Address - Country:US
Mailing Address - Phone:515-278-4234
Mailing Address - Fax:
Practice Address - Street 1:9118 GREENBELT DR
Practice Address - Street 2:
Practice Address - City:URBANDALE
Practice Address - State:IA
Practice Address - Zip Code:50322-7446
Practice Address - Country:US
Practice Address - Phone:515-278-4234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00529133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
379370OtherREGISTERED DIETITIAN
P55708Medicare UPIN
379370OtherREGISTERED DIETITIAN