Provider Demographics
NPI:1326584566
Name:RIESEN, ELIZABETH (RD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:RIESEN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:SERCHEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:W200N9459 WOODSIDE LN
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-1228
Mailing Address - Country:US
Mailing Address - Phone:414-640-3221
Mailing Address - Fax:
Practice Address - Street 1:W200N9459 WOODSIDE LN
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-1228
Practice Address - Country:US
Practice Address - Phone:414-640-3221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-11
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1065583133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered