Provider Demographics
NPI:1669351565
Name:WYATT, MADISON GAYLOR (MS, RDN, LD)
Entity type:Individual
Prefix:MRS
First Name:MADISON
Middle Name:GAYLOR
Last Name:WYATT
Suffix:
Gender:F
Credentials:MS, RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:536 BIG ROCKY BND
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-2638
Mailing Address - Country:US
Mailing Address - Phone:512-797-5347
Mailing Address - Fax:
Practice Address - Street 1:536 BIG ROCKY BND
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-2638
Practice Address - Country:US
Practice Address - Phone:512-797-5347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-27
Last Update Date:2025-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX86131082133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered