Provider Demographics
NPI:1760366991
Name:WIEMERS, MADELINE MAE (RDN)
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:MAE
Last Name:WIEMERS
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1114 W TAYLOR ST APT 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-4254
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1114 W TAYLOR ST APT 3
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-4254
Practice Address - Country:US
Practice Address - Phone:618-806-5177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-01
Last Update Date:2025-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.009357133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered