Healthcare Provider Details

I. General information

NPI: 1841835923
Provider Name (Legal Business Name): ALISSA WOODEN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2019
Last Update Date: 11/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 E 5TH ST
WASHINGTON MO
63090-3127
US

IV. Provider business mailing address

6555 PERNOD AVE
SAINT LOUIS MO
63139-2146
US

V. Phone/Fax

Practice location:
  • Phone: 636-239-8744
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164007753
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2018034593
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: