Provider Demographics
NPI:1801514708
Name:WAGNER, ROSE LYNN (RDN)
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:LYNN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:ROSE
Other - Middle Name:LYNN
Other - Last Name:FLORES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:180 ALTO DR
Mailing Address - Street 2:
Mailing Address - City:OAK VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:93022-9526
Mailing Address - Country:US
Mailing Address - Phone:707-292-8808
Mailing Address - Fax:
Practice Address - Street 1:180 ALTO DR
Practice Address - Street 2:
Practice Address - City:OAK VIEW
Practice Address - State:CA
Practice Address - Zip Code:93022-9526
Practice Address - Country:US
Practice Address - Phone:707-292-8808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-16
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered