Healthcare Provider Details

I. General information

NPI: 1679514038
Provider Name (Legal Business Name): LYNN A WOLLENBERG O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 01/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 N SIDE SQ
CLINTON IL
61727-1657
US

IV. Provider business mailing address

700 N SIDE SQ
CLINTON IL
61727-1657
US

V. Phone/Fax

Practice location:
  • Phone: 217-935-6309
  • Fax: 217-935-3612
Mailing address:
  • Phone: 217-935-6309
  • Fax: 217-935-3612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046-008234
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: