Provider Demographics
NPI:1346725298
Name:WYSOCKI, COLLEEN (MS, RDN)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:WYSOCKI
Suffix:
Gender:F
Credentials:MS, RDN
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:
Other - Last Name:WOODS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, RDN
Mailing Address - Street 1:1637 WESTBRIDGE DR UNIT I1
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-7202
Mailing Address - Country:US
Mailing Address - Phone:970-889-5303
Mailing Address - Fax:
Practice Address - Street 1:677 S COLORADO BLVD STE 100
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80246-8019
Practice Address - Country:US
Practice Address - Phone:970-889-5303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-26
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered