Provider Demographics
NPI:1972247096
Name:WIMMERSTEDT, ALEXANDRA ALYSE
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:ALYSE
Last Name:WIMMERSTEDT
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 1:646 S FLORES ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78204-1219
Mailing Address - Country:US
Mailing Address - Phone:855-481-1149
Mailing Address - Fax:
Practice Address - Street 1:H-E-B, LP 8801 S CONGRESS AVE
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-7389
Practice Address - Country:US
Practice Address - Phone:618-974-1443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-25
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86075428133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered