Provider Demographics
NPI:1659988293
Name:WOLVERTON, JOANNA (RD, CDCES)
Entity Type:Individual
Prefix:MS
First Name:JOANNA
Middle Name:
Last Name:WOLVERTON
Suffix:
Gender:F
Credentials:RD, CDCES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2630 CAMPUS DR
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-1105
Mailing Address - Country:US
Mailing Address - Phone:541-274-2633
Mailing Address - Fax:541-274-2005
Practice Address - Street 1:2630 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-1105
Practice Address - Country:US
Practice Address - Phone:541-274-2633
Practice Address - Fax:541-274-2005
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLD-D-10160301133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered