Provider Demographics
NPI:1184472177
Name:WICKEMEYER, ALYSON (RD)
Entity type:Individual
Prefix:
First Name:ALYSON
Middle Name:
Last Name:WICKEMEYER
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 1:1832 UMSTEAD ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-2348
Mailing Address - Country:US
Mailing Address - Phone:330-806-6595
Mailing Address - Fax:
Practice Address - Street 1:1435 HIGHWAY 258N
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28504-7208
Practice Address - Country:US
Practice Address - Phone:252-523-9094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-07
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL006356133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered