Provider Demographics
NPI:1376627513
Name:WELLSPRING, WANONA (DN)
Entity Type:Individual
Prefix:DR
First Name:WANONA
Middle Name:
Last Name:WELLSPRING
Suffix:
Gender:F
Credentials:DN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8539 W MCCONNELL RD
Mailing Address - Street 2:
Mailing Address - City:WINSLOW
Mailing Address - State:IL
Mailing Address - Zip Code:61089-9227
Mailing Address - Country:US
Mailing Address - Phone:847-312-6143
Mailing Address - Fax:
Practice Address - Street 1:8539 W MCCONNELL RD
Practice Address - Street 2:
Practice Address - City:WINSLOW
Practice Address - State:IL
Practice Address - Zip Code:61089-9227
Practice Address - Country:US
Practice Address - Phone:847-312-6143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL181000242172P00000X
IL181-000242173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
No172P00000XOther Service ProvidersNaprapath