MEDICARE: MRS. STACY JOHNSON WISEMAN RD, LDN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133VN1201X	Obesity and Weight Management Nutrition Registered Dietitian	571	SC

General Provider Information

NPI Number	:	1295464402
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. STACY JOHNSON WISEMAN RD, LDN

Provider Business Mailing Address
First Line	:	4007 MT GALLANT RD
Second Line	:
City	:	ROCK HILL
State	:	SC
Zip	:	29732-9635
Country	:	US
Telephone Number	:	803-323-7505
Fax Number	:

Provider Business Practice Location Address
First Line	:	4007 MT GALLANT RD
Second Line	:
City	:	ROCK HILL
State	:	SC
Zip	:	29732-9635
Country	:	US
Telephone Number	:	803-323-7505
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/06/2022
Last Update Date	:	06/06/2022

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