Provider Demographics
NPI:1326103037
Name:MYERS, WENDI M (MAS, RD, IBCLC)
Entity Type:Individual
Prefix:
First Name:WENDI
Middle Name:M
Last Name:MYERS
Suffix:
Gender:F
Credentials:MAS, RD, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 207
Mailing Address - Street 2:
Mailing Address - City:ESPARTO
Mailing Address - State:CA
Mailing Address - Zip Code:95627-0207
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:233 DOBBINS ST
Practice Address - Street 2:MS 30-100
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-3931
Practice Address - Country:US
Practice Address - Phone:707-469-4597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2012-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ913474133V00000X
CA108-98238174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174N00000XOther Service ProvidersLactation Consultant, Non-RN