Provider Demographics
NPI:1689619397
Name:WANNER, KAY A (LRD, CDE)
Entity Type:Individual
Prefix:
First Name:KAY
Middle Name:A
Last Name:WANNER
Suffix:
Gender:F
Credentials:LRD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4507
Mailing Address - Country:US
Mailing Address - Phone:701-530-6000
Mailing Address - Fax:701-530-6430
Practice Address - Street 1:401 N 9TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4507
Practice Address - Country:US
Practice Address - Phone:701-530-6000
Practice Address - Fax:701-530-6430
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND413133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND52623Medicaid
ND52623Medicaid