Provider Demographics
NPI:1205466448
Name:WAGONER, ADRIANNE
Entity type:Individual
Prefix:
First Name:ADRIANNE
Middle Name:
Last Name:WAGONER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ADRIANNE
Other - Middle Name:
Other - Last Name:DAMLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN
Mailing Address - Street 1:6535 BRANCHES DR
Mailing Address - Street 2:
Mailing Address - City:BROWNSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:46112
Mailing Address - Country:US
Mailing Address - Phone:317-828-3204
Mailing Address - Fax:
Practice Address - Street 1:6535 BRANCHES DR
Practice Address - Street 2:
Practice Address - City:BROWNSBURG
Practice Address - State:IN
Practice Address - Zip Code:46112
Practice Address - Country:US
Practice Address - Phone:317-828-3204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-15
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered