Provider Demographics
NPI:1891252425
Name:BASSINDALE, AMBER MARIE
Entity Type:Individual
Prefix:MRS
First Name:AMBER
Middle Name:MARIE
Last Name:BASSINDALE
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 1:1747 COUNTY CLARE RD
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-7724
Mailing Address - Country:US
Mailing Address - Phone:920-737-7624
Mailing Address - Fax:
Practice Address - Street 1:1747 COUNTY CLARE RD
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-7724
Practice Address - Country:US
Practice Address - Phone:920-737-7624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-01
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1033518133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered