Provider Demographics
NPI:1396890273
Name:WYCKOFF, LISA ANNE (RD, CSR, LD)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANNE
Last Name:WYCKOFF
Suffix:
Gender:F
Credentials:RD, CSR, LD
Other - Prefix:MISS
Other - First Name:LISA
Other - Middle Name:ANNE
Other - Last Name:BARTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9 SHUMARD CT S
Mailing Address - Street 2:
Mailing Address - City:HOMOSASSA
Mailing Address - State:FL
Mailing Address - Zip Code:34446-4720
Mailing Address - Country:US
Mailing Address - Phone:352-382-2048
Mailing Address - Fax:
Practice Address - Street 1:7415 W GULF TO LAKE HWY
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-7834
Practice Address - Country:US
Practice Address - Phone:352-795-1415
Practice Address - Fax:352-564-0147
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND2626133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00025278OtherMEDICARE RAILROAD
FLE6683Medicare ID - Type Unspecified
FLP48307Medicare UPIN