Provider Demographics
NPI:1336158195
Name:WYMAN, THERESE M (RD, CDE)
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:M
Last Name:WYMAN
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:254 EASTON AVE
Mailing Address - Street 2:
Mailing Address - City:NEW BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08901-1766
Mailing Address - Country:US
Mailing Address - Phone:732-339-7630
Mailing Address - Fax:732-745-0969
Practice Address - Street 1:254 EASTON AVE
Practice Address - Street 2:
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-1766
Practice Address - Country:US
Practice Address - Phone:732-745-8600
Practice Address - Fax:732-745-0969
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133NN1002X, 133VN1006X, 133V00000X
NJ644137133V00000X, 133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Provider Identifiers
StateIdentifier IDID TypeIssuer
077231YE06Medicare PIN
077231YE06Medicare Oscar/Certification
NJ077231B3LMedicare ID - Type Unspecified