Provider Demographics
NPI:1598125338
Name:WOMACK, GLYNNIS (RD)
Entity Type:Individual
Prefix:
First Name:GLYNNIS
Middle Name:
Last Name:WOMACK
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 1:25 OAK MANOR CT
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-1779
Mailing Address - Country:US
Mailing Address - Phone:530-828-5027
Mailing Address - Fax:
Practice Address - Street 1:25 OAK MANOR CT
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-1779
Practice Address - Country:US
Practice Address - Phone:530-828-5027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-06
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86031353133V00000X
CO86031353133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered