Healthcare Provider Details

I. General information

NPI: 1063837623
Provider Name (Legal Business Name): EMMA WYSOCKI RDN, PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EMMA COWIE

II. Dates (important events)

Enumeration Date: 02/19/2014
Last Update Date: 09/08/2021
Certification Date: 09/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N ACADEMY AVE
DANVILLE PA
17822-2916
US

IV. Provider business mailing address

114 KINGSLEY AVE
DANVILLE PA
17821-8676
US

V. Phone/Fax

Practice location:
  • Phone: 814-659-9795
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License NumberDI100000554
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License NumberDX3504
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03438811
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: