Provider Demographics
NPI:1033358080
Name:WADA, VANESSA K (RD)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:K
Last Name:WADA
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 1:18200 YORBA LINDA BLVD STE 401
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92886-4061
Mailing Address - Country:US
Mailing Address - Phone:714-646-8000
Mailing Address - Fax:714-572-2562
Practice Address - Street 1:18300 YORBA LINDA BLVD STE 204
Practice Address - Street 2:
Practice Address - City:YORBA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92886-4052
Practice Address - Country:US
Practice Address - Phone:714-577-6031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-16
Last Update Date:2009-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA959673133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA959673OtherREGISTERED LIC