Provider Demographics
NPI:1396213476
Name:SPREEMAN, CARLISSA MAE (RD)
Entity Type:Individual
Prefix:
First Name:CARLISSA
Middle Name:MAE
Last Name:SPREEMAN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:CARLISSA
Other - Middle Name:MAE
Other - Last Name:DIEDRICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:630 S GREEN BAY RD
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-3190
Mailing Address - Country:US
Mailing Address - Phone:920-642-3971
Mailing Address - Fax:844-848-8201
Practice Address - Street 1:630 S GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-3190
Practice Address - Country:US
Practice Address - Phone:920-642-3971
Practice Address - Fax:844-848-8201
Is Sole Proprietor?:No
Enumeration Date:2018-11-07
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered