Provider Demographics
NPI:1568479780
Name:KANE, WENDY R (RD, CDE)
Entity Type:Individual
Prefix:MS
First Name:WENDY
Middle Name:R
Last Name:KANE
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 BLACKLEDGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:COLCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06415
Mailing Address - Country:US
Mailing Address - Phone:860-267-0503
Mailing Address - Fax:860-657-9159
Practice Address - Street 1:972 NEW LONDON TPKE
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-3024
Practice Address - Country:US
Practice Address - Phone:860-267-0503
Practice Address - Fax:860-657-9159
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT000410133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered