Healthcare Provider Details

I. General information

NPI: 1386467629
Provider Name (Legal Business Name): SUMMER WYSE MS, RDN, CD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2024
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5126 W DAYBREAK PKWY
SOUTH JORDAN UT
84009-5994
US

IV. Provider business mailing address

7495 S STATE ST
MIDVALE UT
84047-2013
US

V. Phone/Fax

Practice location:
  • Phone: 801-213-4500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number13942144-4901
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: