Provider Demographics
NPI:1568767655
Name:WILDENBERG, SHELLY RENEE (MS, RD, CD)
Entity Type:Individual
Prefix:MS
First Name:SHELLY
Middle Name:RENEE
Last Name:WILDENBERG
Suffix:
Gender:F
Credentials:MS, RD, CD
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:RENEE
Other - Last Name:FALLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, CDE
Mailing Address - Street 1:1700 W STOUT ST
Mailing Address - Street 2:
Mailing Address - City:RICE LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54868-5000
Mailing Address - Country:US
Mailing Address - Phone:715-236-6139
Mailing Address - Fax:
Practice Address - Street 1:1700 W STOUT ST
Practice Address - Street 2:
Practice Address - City:RICE LAKE
Practice Address - State:WI
Practice Address - Zip Code:54868-5000
Practice Address - Country:US
Practice Address - Phone:715-236-6139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI00965973133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered