Provider Demographics
NPI:1023710779
Name:WISSER, ASHLEY NICHOLE (RDN)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:NICHOLE
Last Name:WISSER
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 BAY BREEZE DR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-5081
Mailing Address - Country:US
Mailing Address - Phone:904-930-1596
Mailing Address - Fax:
Practice Address - Street 1:1100 BAY BREEZE DR
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-5081
Practice Address - Country:US
Practice Address - Phone:904-930-1596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL86174035133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered