Healthcare Provider Details

I. General information

NPI: 1134949530
Provider Name (Legal Business Name): KALEN WEHAGEN NDTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2024
Last Update Date: 10/11/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 CHINN ST
SANTA ROSA CA
95404-4339
US

IV. Provider business mailing address

159 CALIFORNIA AVE
SANTA ROSA CA
95405-4665
US

V. Phone/Fax

Practice location:
  • Phone: 707-687-9187
  • Fax:
Mailing address:
  • Phone: 559-776-9297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code136A00000X
TaxonomyRegistered Dietetic Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: