Provider Demographics
NPI:1518987486
Name:WAGNER, MARLO (RD,CDE)
Entity Type:Individual
Prefix:MRS
First Name:MARLO
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:RD,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5442 E 109TH PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-7247
Mailing Address - Country:US
Mailing Address - Phone:918-296-3910
Mailing Address - Fax:
Practice Address - Street 1:9322 E 41ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74145-3721
Practice Address - Country:US
Practice Address - Phone:918-764-7209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK809909133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered