Basic Information
| Provider Information | |||||||||
| NPI: | 1023233822 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HESSEDAL | ||||||||
| FirstName: | BONNIE | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1405 | ||||||||
| Address2: | |||||||||
| City: | WAUSAU | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544021405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7158472304 | ||||||||
| FaxNumber: | 7158472321 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 E 5TH AVE | ||||||||
| Address2: | |||||||||
| City: | ANTIGO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544092710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156232351 | ||||||||
| FaxNumber: | 7156276183 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2007 | ||||||||
| LastUpdateDate: | 08/12/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 1343-029 | WI | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 1023233822 | 05 | WI | MEDICAID |