Provider Demographics
NPI:1871809103
Name:WELLS, STEPHANIE E
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:E
Last Name:WELLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:MEYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:29373 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1293
Mailing Address - Country:US
Mailing Address - Phone:847-390-5900
Mailing Address - Fax:
Practice Address - Street 1:1675 DEMPSTER ST
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1110
Practice Address - Country:US
Practice Address - Phone:847-723-7181
Practice Address - Fax:847-723-9441
Is Sole Proprietor?:No
Enumeration Date:2010-08-24
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X, 133V00000X, 133VN1004X
IL164.005499133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered