MEDICARE: MS. NANCY M. WISE M.S.,R.D.,L.D/N

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	133V00000X	Registered Dietitian	ND 5781	FL

General Provider Information

NPI Number	:	1730497975
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. NANCY M. WISE M.S.,R.D.,L.D/N

Provider Business Mailing Address
First Line	:	35 CAMBRIDGE TRCE
Second Line	:
City	:	ORMOND BEACH
State	:	FL
Zip	:	32174-2471
Country	:	US
Telephone Number	:	386-675-0790
Fax Number	:	888-785-7846

Provider Business Practice Location Address
First Line	:	35 CAMBRIDGE TRCE
Second Line	:
City	:	ORMOND BEACH
State	:	FL
Zip	:	32174-2471
Country	:	US
Telephone Number	:	386-295-1265
Fax Number	:	888-785-7846

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

Provider Enumeration Date	:	09/22/2010
Last Update Date	:	10/31/2011

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