MEDICARE: CAROLYN WYLY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	136A00000X	Registered Dietetic Technician	DT04433	TX

General Provider Information

NPI Number	:	1417241175
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROLYN WYLY

Provider Business Mailing Address
First Line	:	2620 TANGLEWILDE ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77063-3203
Country	:	US
Telephone Number	:	713-860-8383
Fax Number	:	713-860-8384

Provider Business Practice Location Address
First Line	:	2620 TANGLEWILDE ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77063-3203
Country	:	US
Telephone Number	:	713-860-8383
Fax Number	:	713-860-8384

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/30/2011
Last Update Date	:	05/30/2011

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Directions to “ CAROLYN WYLY ” Practice Location

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