Provider Demographics
NPI:1457827339
Name:WIESE, LINDSAY K (RD LD)
Entity Type:Individual
Prefix:MS
First Name:LINDSAY
Middle Name:K
Last Name:WIESE
Suffix:
Gender:F
Credentials:RD LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4064 E 53RD ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-3033
Mailing Address - Country:US
Mailing Address - Phone:563-355-5540
Mailing Address - Fax:563-359-1137
Practice Address - Street 1:4064 E 53RD ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3033
Practice Address - Country:US
Practice Address - Phone:563-355-5540
Practice Address - Fax:563-359-1137
Is Sole Proprietor?:No
Enumeration Date:2018-10-18
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA089897133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered