Provider Demographics
NPI:1134302565
Name:WAGNER, ELIZABETH (RD, CCN)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:RD, CCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1224 10TH ST STE 207
Mailing Address - Street 2:
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-3420
Mailing Address - Country:US
Mailing Address - Phone:619-437-6600
Mailing Address - Fax:619-437-6603
Practice Address - Street 1:1224 10TH ST STE 207
Practice Address - Street 2:
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-3420
Practice Address - Country:US
Practice Address - Phone:619-437-6600
Practice Address - Fax:619-437-6603
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-07
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist