Provider Demographics
NPI:1619172913
Name:WADUM, MARILYN C (RD, LMNT)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:C
Last Name:WADUM
Suffix:
Gender:F
Credentials:RD, LMNT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5506 S 104TH CIR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68127-3036
Mailing Address - Country:US
Mailing Address - Phone:402-592-3610
Mailing Address - Fax:
Practice Address - Street 1:8601 W DODGE RD
Practice Address - Street 2:SUITE # 30
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-3457
Practice Address - Country:US
Practice Address - Phone:402-354-8797
Practice Address - Fax:402-354-5651
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE183133N00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered133N00000XDietary & Nutritional Service ProvidersNutritionist
Not Answered133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE183OtherRD LICENSE