Provider Demographics
NPI:1942912019
Name:WAGNER, SAMANTHA (RDN)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2960 N CIRCLE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-1163
Mailing Address - Country:US
Mailing Address - Phone:719-634-8891
Mailing Address - Fax:
Practice Address - Street 1:2960 N CIRCLE DR STE 200
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-1163
Practice Address - Country:US
Practice Address - Phone:719-634-8891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-20
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO86289910133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered