Healthcare Provider Details

I. General information

NPI: 1255638797
Provider Name (Legal Business Name): WISE NUTRITION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2011
Last Update Date: 11/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 CAMBRIDGE TRCE
ORMOND BEACH FL
32174-2471
US

IV. Provider business mailing address

35 CAMBRIDGE TRCE
ORMOND BEACH FL
32174-2471
US

V. Phone/Fax

Practice location:
  • Phone: 386-675-0790
  • Fax: 888-785-7846
Mailing address:
  • Phone: 386-675-0790
  • Fax: 888-785-7846

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License NumberND5781
License Number StateFL

VIII. Authorized Official

Name: MRS. NANCY M WISE
Title or Position: SOLE PROPRIETOR
Credential: MS/RD/LD/N
Phone: 386-295-1265