Provider Demographics
NPI:1346416740
Name:WAGNER, EDYE LYNN (RD, LDN)
Entity Type:Individual
Prefix:MS
First Name:EDYE
Middle Name:LYNN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 N WESTMORELAND RD
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1659
Mailing Address - Country:US
Mailing Address - Phone:847-234-5600
Mailing Address - Fax:847-535-7851
Practice Address - Street 1:660 N WESTMORELAND RD
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1659
Practice Address - Country:US
Practice Address - Phone:847-234-5600
Practice Address - Fax:847-535-7851
Is Sole Proprietor?:No
Enumeration Date:2008-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164000949133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered