Provider Demographics
NPI:1225209364
Name:WACK, GINA M (MS,RD)
Entity Type:Individual
Prefix:MRS
First Name:GINA
Middle Name:M
Last Name:WACK
Suffix:
Gender:F
Credentials:MS,RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 SPRING OAK DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-9131
Mailing Address - Country:US
Mailing Address - Phone:601-605-9382
Mailing Address - Fax:
Practice Address - Street 1:127 SPRING OAK DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-9131
Practice Address - Country:US
Practice Address - Phone:601-605-9382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-17
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD0500133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered