Provider Demographics
NPI:1316194095
Name:WYNNE, NICOLE (RD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WYNNE
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 1:200 EDIE ANN DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-5325
Mailing Address - Country:US
Mailing Address - Phone:337-739-0293
Mailing Address - Fax:
Practice Address - Street 1:200 EDIE ANN DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-5325
Practice Address - Country:US
Practice Address - Phone:337-739-0293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-25
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1770133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered