Provider Demographics
NPI:1699094433
Name:WISEMAN, SUSAN MARIE (RD, LD)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MARIE
Last Name:WISEMAN
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:MARIE
Other - Last Name:GERDEMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD,LD
Mailing Address - Street 1:200 SAINT CLAIR AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:OH
Mailing Address - Zip Code:45885-2400
Mailing Address - Country:US
Mailing Address - Phone:419-394-3335
Mailing Address - Fax:
Practice Address - Street 1:200 SAINT CLAIR AVE
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:OH
Practice Address - Zip Code:45885-2400
Practice Address - Country:US
Practice Address - Phone:419-394-3335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-19
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4435133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered