Healthcare Provider Details

I. General information

NPI: 1396890273
Provider Name (Legal Business Name): LISA ANNE WYCKOFF RD, CSR, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MISS LISA ANNE BARTON

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7415 W GULF TO LAKE HWY
CRYSTAL RIVER FL
34429-7834
US

IV. Provider business mailing address

9 SHUMARD CT S
HOMOSASSA FL
34446-4720
US

V. Phone/Fax

Practice location:
  • Phone: 352-795-1415
  • Fax: 352-564-0147
Mailing address:
  • Phone: 352-382-2048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License NumberND2626
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: