Provider Demographics
NPI:1306671862
Name:WICHERN, SARAH (RD)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:WICHERN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2751 HAWTHORNE RD
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-4230
Mailing Address - Country:US
Mailing Address - Phone:573-382-1016
Mailing Address - Fax:
Practice Address - Street 1:2751 HAWTHORNE RD
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-4230
Practice Address - Country:US
Practice Address - Phone:573-382-1016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-04
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024029598133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered