Provider Demographics
NPI:1851656243
Name:TUTT, WANDA W (LRD)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:W
Last Name:TUTT
Suffix:
Gender:F
Credentials:LRD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 REVOLUTIONARY TRL
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:SC
Mailing Address - Zip Code:29827-7109
Mailing Address - Country:US
Mailing Address - Phone:803-632-2533
Mailing Address - Fax:803-632-3757
Practice Address - Street 1:333 REVOLUTIONARY TRL
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:SC
Practice Address - Zip Code:29827-7109
Practice Address - Country:US
Practice Address - Phone:803-632-2533
Practice Address - Fax:803-632-3757
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC261133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered