Provider Demographics
NPI:1164058392
Name:WONG, HEI JESSIE (RDN, LD)
Entity Type:Individual
Prefix:
First Name:HEI JESSIE
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7001
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47407-7001
Mailing Address - Country:US
Mailing Address - Phone:202-468-9800
Mailing Address - Fax:
Practice Address - Street 1:929 S FENBROOK CT
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-4814
Practice Address - Country:US
Practice Address - Phone:202-468-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-19
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37002816A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered