Provider Demographics
NPI:1730497975
Name:WISE, NANCY M (MS,RD,LD/N)
Entity Type:Individual
Prefix:MS
First Name:NANCY
Middle Name:M
Last Name:WISE
Suffix:
Gender:F
Credentials:MS,RD,LD/N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 CAMBRIDGE TRCE
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-2471
Mailing Address - Country:US
Mailing Address - Phone:386-675-0790
Mailing Address - Fax:888-785-7846
Practice Address - Street 1:35 CAMBRIDGE TRCE
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-2471
Practice Address - Country:US
Practice Address - Phone:386-295-1265
Practice Address - Fax:888-785-7846
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-22
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND 5781133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered