Provider Demographics
NPI:1285863563
Name:WYATT, AMANDA (RD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WYATT
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 SCHOOL PL
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19963-1821
Mailing Address - Country:US
Mailing Address - Phone:302-222-4736
Mailing Address - Fax:
Practice Address - Street 1:32060 LONG NECK RD
Practice Address - Street 2:
Practice Address - City:MILLSBORO
Practice Address - State:DE
Practice Address - Zip Code:19966-6228
Practice Address - Country:US
Practice Address - Phone:302-947-2909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-08
Last Update Date:2009-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEDN-0000303133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered