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General NPI Number Information
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NPI Number | 1255638797
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Entity Type | Organization
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Legal Business Name | WISE NUTRITION LLC
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Dates
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Enumeration Date | 02/18/2011
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Last Update Date | 11/01/2011
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Provider Practice Location Address
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Address Line | 35 CAMBRIDGE TRCE
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City | ORMOND BEACH
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State | FL
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Zip | 32174-2471
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Country | US
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Telephone | 386-675-0790
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Fax | 888-785-7846
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Provider Business Mailing Address
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Address Line | 35 CAMBRIDGE TRCE
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City | ORMOND BEACH
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State | FL
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Zip | 32174-2471
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Country | US
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Telephone | 386-675-0790
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Fax | 888-785-7846
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Authorized Official
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Title or Position | SOLE PROPRIETOR
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Name | MRS. NANCY M WISE
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Credential | MS/RD/LD/N
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Telephone | 386-295-1265
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133VN1005X
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Taxonomy Name | Renal Nutrition Registered Dietitian
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License Number | ND5781
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License Number State | FL
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