Provider Demographics
NPI:1831918309
Name:WAGNER, ANDREA (RD, RDN)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:RD, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2711 PARKWAY CT
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54494-7357
Mailing Address - Country:US
Mailing Address - Phone:715-252-4132
Mailing Address - Fax:
Practice Address - Street 1:2711 PARKWAY CT
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-7357
Practice Address - Country:US
Practice Address - Phone:715-252-4132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-10
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI86028262133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered