Provider Demographics
NPI:1760076202
Name:WILD, LUCY (RD)
Entity Type:Individual
Prefix:
First Name:LUCY
Middle Name:
Last Name:WILD
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 1:3422 SW FALCON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-3731
Mailing Address - Country:US
Mailing Address - Phone:339-227-1161
Mailing Address - Fax:
Practice Address - Street 1:1450 GARDEN ST
Practice Address - Street 2:
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030-4595
Practice Address - Country:US
Practice Address - Phone:732-963-6670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-25
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered