Healthcare Provider Details

I. General information

NPI: 1881823292
Provider Name (Legal Business Name): VIVA MARIE JOHANKNECHT MS RD CD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2009
Last Update Date: 07/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 TRI PARK WAY
APPLETON WI
54914-1658
US

IV. Provider business mailing address

1241 WHEATFIELD WAY
OSHKOSH WI
54904
US

V. Phone/Fax

Practice location:
  • Phone: 920-831-0070
  • Fax:
Mailing address:
  • Phone: 920-426-0247
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1709-029
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: