Provider Demographics
NPI:1033356977
Name:WIEDENMAN, MELITA (MS, RD, LN)
Entity Type:Individual
Prefix:
First Name:MELITA
Middle Name:
Last Name:WIEDENMAN
Suffix:
Gender:F
Credentials:MS, RD, LN
Other - Prefix:
Other - First Name:MELITA
Other - Middle Name:
Other - Last Name:WILBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, RD, LN
Mailing Address - Street 1:1929 EILERS CT
Mailing Address - Street 2:
Mailing Address - City:HURON
Mailing Address - State:SD
Mailing Address - Zip Code:57350-3846
Mailing Address - Country:US
Mailing Address - Phone:605-352-9034
Mailing Address - Fax:605-352-9034
Practice Address - Street 1:1929 EILERS CT
Practice Address - Street 2:
Practice Address - City:HURON
Practice Address - State:SD
Practice Address - Zip Code:57350-3846
Practice Address - Country:US
Practice Address - Phone:605-352-9034
Practice Address - Fax:605-352-9034
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-14
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0035133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered