Provider Demographics
NPI:1326502832
Name:DOHERTY NUTRITION LLC
Entity Type:Organization
Organization Name:DOHERTY NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTA
Authorized Official - Middle Name:
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-372-2022
Mailing Address - Street 1:17060 DALLAS PKWY STE 112
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248-1905
Mailing Address - Country:US
Mailing Address - Phone:469-372-2022
Mailing Address - Fax:833-290-5413
Practice Address - Street 1:17060 DALLAS PKWY STE 112
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75248-1905
Practice Address - Country:US
Practice Address - Phone:469-372-2022
Practice Address - Fax:833-290-5413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-29
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty