Provider Demographics
NPI:1275293623
Name:WILSON, HALEY BROOKE (RDN,LD,CSCS)
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:BROOKE
Last Name:WILSON
Suffix:
Gender:F
Credentials:RDN,LD,CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1811 IRIS ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72202-1623
Mailing Address - Country:US
Mailing Address - Phone:620-750-0349
Mailing Address - Fax:
Practice Address - Street 1:1811 IRIS ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72202-1623
Practice Address - Country:US
Practice Address - Phone:620-750-0349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-27
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2106133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered