Provider Demographics
NPI:1033906003
Name:WYATT, JULIA ELIZABETH
Entity type:Individual
Prefix:
First Name:JULIA
Middle Name:ELIZABETH
Last Name:WYATT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11328 CRESSKILL CT
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-2008
Mailing Address - Country:US
Mailing Address - Phone:260-437-4675
Mailing Address - Fax:
Practice Address - Street 1:11328 CRESSKILL CT
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-2008
Practice Address - Country:US
Practice Address - Phone:260-437-4675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-23
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37000100A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered