Provider Demographics
NPI:1710509070
Name:WIESE, ANNA (RD)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:WIESE
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 1:9362 AMISON CIR APT 101
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80134-7698
Mailing Address - Country:US
Mailing Address - Phone:615-785-0612
Mailing Address - Fax:
Practice Address - Street 1:9362 AMISON CIR APT 101
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80134-7698
Practice Address - Country:US
Practice Address - Phone:615-785-0612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-10
Last Update Date:2020-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO86082053133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered