Provider Demographics
NPI:1417564055
Name:WIENER, GINA (RD)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:WIENER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 MILLER CT
Mailing Address - Street 2:
Mailing Address - City:RIO DELL
Mailing Address - State:CA
Mailing Address - Zip Code:95562-1132
Mailing Address - Country:US
Mailing Address - Phone:707-834-7114
Mailing Address - Fax:
Practice Address - Street 1:1121 MILLER CT
Practice Address - Street 2:
Practice Address - City:RIO DELL
Practice Address - State:CA
Practice Address - Zip Code:95562-1132
Practice Address - Country:US
Practice Address - Phone:707-834-7114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA894252133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered