Provider Demographics
NPI:1023233822
Name:HESSEDAL, BONNIE J (RD)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:J
Last Name:HESSEDAL
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:PO BOX 1405
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54402-1405
Mailing Address - Country:US
Mailing Address - Phone:715-847-2304
Mailing Address - Fax:715-847-2321
Practice Address - Street 1:110 E 5TH AVE
Practice Address - Street 2:
Practice Address - City:ANTIGO
Practice Address - State:WI
Practice Address - Zip Code:54409-2710
Practice Address - Country:US
Practice Address - Phone:715-623-2351
Practice Address - Fax:715-627-6183
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1343-029133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1023233822Medicaid