Provider Demographics
NPI:1972327278
Name:WIEDEMAN, ALYSSA (RDN)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:WIEDEMAN
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:NA
Other - Middle Name:NA
Other - Last Name:NA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NA
Mailing Address - Street 1:609 SE 13TH CT
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-2622
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:609 SE 13TH CT
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-2622
Practice Address - Country:US
Practice Address - Phone:239-360-7942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-13
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12536133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered