Provider Demographics
NPI:1932317609
Name:WHITESIDES, WENDY L
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:L
Last Name:WHITESIDES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:
Other - Last Name:SEAMONS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:238 S 50 W
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-5697
Mailing Address - Country:US
Mailing Address - Phone:208-678-8155
Mailing Address - Fax:
Practice Address - Street 1:1501 HILAND AVE
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2682
Practice Address - Country:US
Practice Address - Phone:208-678-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-161133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered