Healthcare Provider Details

I. General information

NPI: 1043648090
Provider Name (Legal Business Name): LYNNE WENTZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LYNNE PUTNAM RN, BSN, MHS, CDE

II. Dates (important events)

Enumeration Date: 10/29/2013
Last Update Date: 10/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 W 68TH ST RM.S 409
CHICAGO IL
60629-1813
US

IV. Provider business mailing address

23815 S RAYMOND DR
CRETE IL
60417-1863
US

V. Phone/Fax

Practice location:
  • Phone: 773-884-9899
  • Fax:
Mailing address:
  • Phone: 708-275-6578
  • Fax: 708-367-0713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number041.240560
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number041.240560
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: