Provider Demographics
NPI:1679514038
Name:WOLLENBERG, LYNN A (OD)
Entity Type:Individual
Prefix:DR
First Name:LYNN
Middle Name:A
Last Name:WOLLENBERG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 N SIDE SQ
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IL
Mailing Address - Zip Code:61727-1657
Mailing Address - Country:US
Mailing Address - Phone:217-935-6309
Mailing Address - Fax:217-935-3612
Practice Address - Street 1:700 N SIDE SQ
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IL
Practice Address - Zip Code:61727-1657
Practice Address - Country:US
Practice Address - Phone:217-935-6309
Practice Address - Fax:217-935-3612
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008234152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01584010OtherBLUE CROSS BLUE SHIELD
IL0160990001Medicare NSC
IL946381Medicare ID - Type Unspecified
ILT90516Medicare UPIN