Provider Demographics
NPI:1689334955
Name:SEIDEL, ALYSSA MCKENNA (RDN)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:MCKENNA
Last Name:SEIDEL
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 PONDEROSA DR
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:SD
Mailing Address - Zip Code:57785-2711
Mailing Address - Country:US
Mailing Address - Phone:406-698-2464
Mailing Address - Fax:
Practice Address - Street 1:1440 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SPEARFISH
Practice Address - State:SD
Practice Address - Zip Code:57783-1505
Practice Address - Country:US
Practice Address - Phone:605-644-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-28
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0795133V00000X
MTMED-NUTR-LIC-91319133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered