Provider Demographics
NPI:1699828426
Name:WISE, KATHY G (RD,)
Entity Type:Individual
Prefix:MRS
First Name:KATHY
Middle Name:G
Last Name:WISE
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 1:4974 HIGBEE AVE NW
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2562
Mailing Address - Country:US
Mailing Address - Phone:330-493-4666
Mailing Address - Fax:330-493-4849
Practice Address - Street 1:4974 HIGBEE AVE NW
Practice Address - Street 2:SUITE 100
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2562
Practice Address - Country:US
Practice Address - Phone:330-493-4666
Practice Address - Fax:330-493-4849
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD917133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHMT00931Medicare ID - Type Unspecified