Provider Demographics
NPI:1720094717
Name:WILBORN, THELMA (RD,LD)
Entity type:Individual
Prefix:MRS
First Name:THELMA
Middle Name:
Last Name:WILBORN
Suffix:
Gender:F
Credentials:RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 PRIMROSE DR
Mailing Address - Street 2:
Mailing Address - City:KYLE
Mailing Address - State:TX
Mailing Address - Zip Code:78640-8848
Mailing Address - Country:US
Mailing Address - Phone:512-268-2005
Mailing Address - Fax:
Practice Address - Street 1:2901 MONTOPOLIS DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78741-6411
Practice Address - Country:US
Practice Address - Phone:512-389-6531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT01258133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered