Provider Demographics
NPI:1205038486
Name:WOLF, CYDNEY JARED (RD)
Entity type:Individual
Prefix:MRS
First Name:CYDNEY
Middle Name:JARED
Last Name:WOLF
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 1:111 COLCHESTER AVE
Mailing Address - Street 2:ENGINEERING 328
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-1473
Mailing Address - Country:US
Mailing Address - Phone:802-847-4760
Mailing Address - Fax:
Practice Address - Street 1:1 S PROSPECT ST
Practice Address - Street 2:RENAL SERVICES
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-3456
Practice Address - Country:US
Practice Address - Phone:802-847-3572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT074-85133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTMT0120Medicare ID - Type Unspecified