Provider Demographics
NPI:1578822813
Name:WYATT, BIANCA (RD, LD, CNSC)
Entity Type:Individual
Prefix:
First Name:BIANCA
Middle Name:
Last Name:WYATT
Suffix:
Gender:F
Credentials:RD, LD, CNSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:342 FAIRVIEW ST
Mailing Address - Street 2:
Mailing Address - City:SILVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97381-1917
Mailing Address - Country:US
Mailing Address - Phone:503-873-1500
Mailing Address - Fax:
Practice Address - Street 1:240 PHELPS ST
Practice Address - Street 2:
Practice Address - City:SILVERTON
Practice Address - State:OR
Practice Address - Zip Code:97381-1927
Practice Address - Country:US
Practice Address - Phone:503-873-1560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-07
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLD-D-10147476133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered