Provider Demographics
NPI:1457104416
Name:GOTTWALD, ALYSSA (RDN)
Entity Type:Individual
Prefix:MRS
First Name:ALYSSA
Middle Name:
Last Name:GOTTWALD
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 1:202 STONEBROOK DR
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-1271
Mailing Address - Country:US
Mailing Address - Phone:262-424-9895
Mailing Address - Fax:
Practice Address - Street 1:202 STONEBROOK DR
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-1271
Practice Address - Country:US
Practice Address - Phone:262-424-9895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-09
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3270-29133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered