Provider Demographics
NPI:1720384589
Name:VAGT, KIM MARIE (MS, RD, CDE)
Entity Type:Individual
Prefix:MS
First Name:KIM
Middle Name:MARIE
Last Name:VAGT
Suffix:
Gender:F
Credentials:MS, RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MISSION BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:CA
Mailing Address - Zip Code:95642-2564
Mailing Address - Country:US
Mailing Address - Phone:209-223-7430
Mailing Address - Fax:209-257-7634
Practice Address - Street 1:200 MISSION BLVD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95642-2564
Practice Address - Country:US
Practice Address - Phone:209-223-7430
Practice Address - Fax:209-257-7634
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-26
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA013949133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered