Healthcare Provider Details

I. General information

NPI: 1184228306
Provider Name (Legal Business Name): WESLEY JOB MAYEUX RDN, CSSD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2020
Last Update Date: 08/26/2024
Certification Date: 08/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 JARRETT WHITE RD
TRIPLER AMC HI
96859-5001
US

IV. Provider business mailing address

1218 PIKAKE ST
WAHIAWA HI
96786-6021
US

V. Phone/Fax

Practice location:
  • Phone: 936-668-1581
  • Fax:
Mailing address:
  • Phone: 936-668-1581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86108438
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code133VN1501X
TaxonomySports Dietetics Nutrition Registered Dietitian
License Number86108438
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: