Healthcare Provider Details

I. General information

NPI: 1427432731
Provider Name (Legal Business Name): GWENDOLYN ANN WITTENBROOK MA, RD, CSP, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: WENDY WITTENBROOK MA, RD, CSP, LD

II. Dates (important events)

Enumeration Date: 07/16/2015
Last Update Date: 11/19/2025
Certification Date: 11/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12606 GREENVILLE AVE STE 200
DALLAS TX
75243-1923
US

IV. Provider business mailing address

12606 GREENVILLE AVE STE 200
DALLAS TX
75243-1923
US

V. Phone/Fax

Practice location:
  • Phone: 469-780-4590
  • Fax: 972-437-1988
Mailing address:
  • Phone: 469-780-4590
  • Fax: 972-437-1988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT05870
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License NumberDT05780
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: