Provider Demographics
NPI:1053909952
Name:WYNNE, JANE (MS, RD)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:WYNNE
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 E MAIN ST STE A883
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06901-2113
Mailing Address - Country:US
Mailing Address - Phone:203-978-3558
Mailing Address - Fax:
Practice Address - Street 1:680 E MAIN ST STE A883
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06901-2113
Practice Address - Country:US
Practice Address - Phone:203-978-3558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-06
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86106302133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered