Provider Demographics
NPI:1073811998
Name:WISSE, STEFANIE JEAN (RD)
Entity Type:Individual
Prefix:MRS
First Name:STEFANIE
Middle Name:JEAN
Last Name:WISSE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MS
Other - First Name:STEFANIE
Other - Middle Name:JEAN
Other - Last Name:HERRINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:820 MEMORIAL ST STE 1
Mailing Address - Street 2:
Mailing Address - City:PROSSER
Mailing Address - State:WA
Mailing Address - Zip Code:99350-2504
Mailing Address - Country:US
Mailing Address - Phone:509-786-2010
Mailing Address - Fax:509-788-1794
Practice Address - Street 1:820 MEMORIAL ST STE 1
Practice Address - Street 2:
Practice Address - City:PROSSER
Practice Address - State:WA
Practice Address - Zip Code:99350-2504
Practice Address - Country:US
Practice Address - Phone:509-786-2010
Practice Address - Fax:509-788-1794
Is Sole Proprietor?:No
Enumeration Date:2011-03-01
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI60114384133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered