Basic Information
| Provider Information | |||||||||
| NPI: | 1073811998 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WISSE | ||||||||
| FirstName: | STEFANIE | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HERRINGTON | ||||||||
| OtherFirstName: | STEFANIE | ||||||||
| OtherMiddleName: | JEAN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 820 MEMORIAL ST., SUITE 1 | ||||||||
| Address2: | |||||||||
| City: | PROSSER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5097862010 | ||||||||
| FaxNumber: | 5097881794 | ||||||||
| Practice Location | |||||||||
| Address1: | 820 MEMORIAL ST., SUITE 1 | ||||||||
| Address2: | |||||||||
| City: | PROSSER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5097862010 | ||||||||
| FaxNumber: | 5097881794 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2011 | ||||||||
| LastUpdateDate: | 05/08/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.