Provider Demographics
NPI:1871341263
Name:TYWANICK, KYRA (RDN)
Entity type:Individual
Prefix:
First Name:KYRA
Middle Name:
Last Name:TYWANICK
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 FIELDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08809-1390
Mailing Address - Country:US
Mailing Address - Phone:908-894-4561
Mailing Address - Fax:
Practice Address - Street 1:155 HAZEL ST
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07011-3423
Practice Address - Country:US
Practice Address - Phone:973-772-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-09
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ86210089133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered