Provider Demographics
NPI:1750636031
Name:WYATT, TRACEY LYNN (RD)
Entity Type:Individual
Prefix:MS
First Name:TRACEY
Middle Name:LYNN
Last Name:WYATT
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2101 E JEFFERSON ST
Mailing Address - Street 2:KAISER PERMANENTE MEDICARE ENROLLMENT
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-2424
Mailing Address - Fax:
Practice Address - Street 1:8008 WESTPARK DR
Practice Address - Street 2:KAISER PERMANENTE TYSONS CORNER MEDICAL CENTER
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22102-3109
Practice Address - Country:US
Practice Address - Phone:703-287-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-23
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA962035133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA962035OtherCOMMISSION ON DIETETIC REGISTRATION