Provider Demographics
NPI:1275096364
Name:WAGNER, TERESA L (DRPH, MS, CPH, RD/LD)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:L
Last Name:WAGNER
Suffix:
Gender:F
Credentials:DRPH, MS, CPH, RD/LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 MONTGOMERY ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-2553
Mailing Address - Country:US
Mailing Address - Phone:817-735-0387
Mailing Address - Fax:
Practice Address - Street 1:5841 RECREATION DR APT 2404
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-1068
Practice Address - Country:US
Practice Address - Phone:817-805-1252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-08
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT02954133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX393OtherCERTIFIED COMMUNITY HEALTH WORKER INSTRUCTOR
10551OtherNATIONAL BOARD OF PUBLIC HEALTH EXAMINERS
TXDT02954OtherLICENSED DIETITIAN
709400OtherREGISTERED DIETITIAN