Provider Demographics
NPI:1407890452
Name:WILSON, ROBYN RHEA (MS, RD, LD)
Entity Type:Individual
Prefix:
First Name:ROBYN
Middle Name:RHEA
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:ROBYN
Other - Middle Name:RHEA
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19 PINE BURR CIR
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:TX
Mailing Address - Zip Code:75672-4767
Mailing Address - Country:US
Mailing Address - Phone:903-923-8529
Mailing Address - Fax:
Practice Address - Street 1:2901 N 4TH ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-5128
Practice Address - Country:US
Practice Address - Phone:903-233-4749
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT06611133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8G5378Medicare ID - Type Unspecified