Provider Demographics
NPI:1972853646
Name:WOLLENBERG, MEGAN ELISSA (RD)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:ELISSA
Last Name:WOLLENBERG
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 VERNON ST UNIT 40
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-3967
Mailing Address - Country:US
Mailing Address - Phone:530-906-3814
Mailing Address - Fax:
Practice Address - Street 1:1675 VERNON ST UNIT 40
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-3967
Practice Address - Country:US
Practice Address - Phone:530-906-3814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-10
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1096590133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered