Provider Demographics
NPI:1003614843
Name:MISSEY, WENDY J (MS RD LDN)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:J
Last Name:MISSEY
Suffix:
Gender:
Credentials:MS RD LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:834 RUSSELL CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:IL
Mailing Address - Zip Code:62236-1548
Mailing Address - Country:US
Mailing Address - Phone:618-420-6177
Mailing Address - Fax:
Practice Address - Street 1:834 RUSSELL CT
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:IL
Practice Address - Zip Code:62236-1548
Practice Address - Country:US
Practice Address - Phone:618-420-6177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-06
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.004707133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered