Provider Demographics
NPI:1184034589
Name:WISSING, VANESSA
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:WISSING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3411 WAYNE AVE
Mailing Address - Street 2:SUITE 4M
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-2509
Mailing Address - Country:US
Mailing Address - Phone:718-920-7394
Mailing Address - Fax:
Practice Address - Street 1:3415 BAINBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2403
Practice Address - Country:US
Practice Address - Phone:718-920-7394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-07
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1025483133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered