Healthcare Provider Details

I. General information

NPI: 1164515367
Provider Name (Legal Business Name): JENNIFER LYNNE BALDINI RD,CD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4404 STATE ROAD 70
WEBSTER WI
54893-9251
US

IV. Provider business mailing address

214 7TH AVE
SHELL LAKE WI
54871-7610
US

V. Phone/Fax

Practice location:
  • Phone: 715-349-8554
  • Fax:
Mailing address:
  • Phone: 715-349-8554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1677
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: