Healthcare Provider Details

I. General information

NPI: 1699699710
Provider Name (Legal Business Name): OLIVIA HANNA WYMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2026
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 STATE ST STE 310
BANGOR ME
04401-6623
US

IV. Provider business mailing address

2841 BENNOCH RD
ALTON ME
04468-4200
US

V. Phone/Fax

Practice location:
  • Phone: 207-973-6383
  • Fax:
Mailing address:
  • Phone: 207-248-2145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberTD2378
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: