Provider Demographics
NPI:1720238116
Name:RYDELL, WENDY ELAINE (RD)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:ELAINE
Last Name:RYDELL
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N5458 COUNTY RD E
Mailing Address - Street 2:
Mailing Address - City:PORTERFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54159-9701
Mailing Address - Country:US
Mailing Address - Phone:715-789-2990
Mailing Address - Fax:
Practice Address - Street 1:3100 SHORE DR
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-4242
Practice Address - Country:US
Practice Address - Phone:715-735-4200
Practice Address - Fax:715-735-8017
Is Sole Proprietor?:No
Enumeration Date:2008-09-23
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI417-029133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI70020150000038611482Medicare PIN