Provider Demographics
NPI:1235492570
Name:WAGNER, KAYLA ROSE (RD, LD)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:ROSE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
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Mailing Address - Street 1:712 S CASCADE ST
Mailing Address - Street 2:
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537-2913
Mailing Address - Country:US
Mailing Address - Phone:218-736-8000
Mailing Address - Fax:218-736-8719
Practice Address - Street 1:712 S CASCADE ST
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-2913
Practice Address - Country:US
Practice Address - Phone:218-736-8000
Practice Address - Fax:218-736-8719
Is Sole Proprietor?:No
Enumeration Date:2012-06-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN3119133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN10050503OtherSERVSAFE
MN3119OtherBOARD OF DIETETICS & NUTRITION PRACTICE
XE20265137OtherNATIONAL REGISTRY OF FOOD SAFETY CERTIFIED FOOD SAFETY MANAGER
MN86007314OtherACADEMY OF NUTRITION AND DIETETICS VERIFICATION