MEDICARE: MRS. LISA ANNE WYCKOFF RD, CSR, LD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133VN1005X	Renal Nutrition Registered Dietitian	ND2626	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00025278	OTHER	FL	MEDICARE RAILROAD

General Provider Information

NPI Number	:	1396890273
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA ANNE WYCKOFF RD, CSR, LD

Provider Business Mailing Address
First Line	:	9 SHUMARD CT S
Second Line	:
City	:	HOMOSASSA
State	:	FL
Zip	:	34446-4720
Country	:	US
Telephone Number	:	352-382-2048
Fax Number	:

Provider Business Practice Location Address
First Line	:	7415 W GULF TO LAKE HWY
Second Line	:
City	:	CRYSTAL RIVER
State	:	FL
Zip	:	34429-7834
Country	:	US
Telephone Number	:	352-795-1415
Fax Number	:	352-564-0147

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/24/2007
Last Update Date	:	07/08/2007

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