Provider Demographics
NPI:1184214108
Name:WYNNE, BRIANNA KAY (MS, RD, LDN)
Entity Type:Individual
Prefix:
First Name:BRIANNA
Middle Name:KAY
Last Name:WYNNE
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629 W DEMING PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-2693
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19805 S LA GRANGE RD
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-8348
Practice Address - Country:US
Practice Address - Phone:708-938-3378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-23
Last Update Date:2021-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164007804133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered