Provider Demographics
NPI:1710397377
Name:FISHER, WENDY
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:FISHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-2724
Mailing Address - Country:US
Mailing Address - Phone:505-367-0365
Mailing Address - Fax:
Practice Address - Street 1:1010 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2724
Practice Address - Country:US
Practice Address - Phone:505-367-0365
Practice Address - Fax:505-367-0362
Is Sole Proprietor?:No
Enumeration Date:2014-05-05
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLD-0910133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered