Provider Demographics
NPI:1467891994
Name:WAGNER, AMANDA DIANE (RD)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:DIANE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5405 TUCKERMAN LN APT 425
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-7311
Mailing Address - Country:US
Mailing Address - Phone:301-400-2702
Mailing Address - Fax:
Practice Address - Street 1:9040 JACKSON AVENUE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-7311
Practice Address - Country:US
Practice Address - Phone:352-968-1631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-18
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered