Healthcare Provider Details

I. General information

NPI: 1538542733
Provider Name (Legal Business Name): WENDY M BROEKEMA MS, RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6155 GRAND AVE
GURNEE IL
60031-1651
US

IV. Provider business mailing address

6155 GRAND AVE
GURNEE IL
60031-1651
US

V. Phone/Fax

Practice location:
  • Phone: 847-535-7647
  • Fax: 847-535-8109
Mailing address:
  • Phone: 847-535-7647
  • Fax: 847-535-8109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164008069
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number3313
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number146635
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: