Healthcare Provider Details

I. General information

NPI: 1417241175
Provider Name (Legal Business Name): CAROLYN WYLY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2011
Last Update Date: 05/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 TANGLEWILDE ST
HOUSTON TX
77063-3203
US

IV. Provider business mailing address

2620 TANGLEWILDE ST
HOUSTON TX
77063-3203
US

V. Phone/Fax

Practice location:
  • Phone: 713-860-8383
  • Fax: 713-860-8384
Mailing address:
  • Phone: 713-860-8383
  • Fax: 713-860-8384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code136A00000X
TaxonomyRegistered Dietetic Technician
License NumberDT04433
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: