Basic Information
| Provider Information | |||||||||
| NPI: | 1689334955 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SEIDEL | ||||||||
| FirstName: | ALYSSA | ||||||||
| MiddleName: | MCKENNA | ||||||||
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| Credential: | RDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1207 PONDEROSA DR | ||||||||
| Address2: | |||||||||
| City: | STURGIS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577852711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4066982464 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1440 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SPEARFISH | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577831505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6056444000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2021 | ||||||||
| LastUpdateDate: | 12/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 0795 | SD | Y | Dietary & Nutritional Service Providers | Dietitian, Registered | 133V00000X | MED-NUTR-LIC-91319 | MT | N | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.