Provider Demographics
NPI:1346423084
Name:LAFONTAINE, WENDY C (RD)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:C
Last Name:LAFONTAINE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 SAN MARINO RD
Mailing Address - Street 2:
Mailing Address - City:GREGORY
Mailing Address - State:MI
Mailing Address - Zip Code:48137-9434
Mailing Address - Country:US
Mailing Address - Phone:734-498-2144
Mailing Address - Fax:
Practice Address - Street 1:420 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-2445
Practice Address - Country:US
Practice Address - Phone:810-257-3724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-17
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI806628133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered