Healthcare Provider Details

I. General information

NPI: 1619172913
Provider Name (Legal Business Name): MARILYN C. WADUM RD, LMNT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8601 W DODGE RD SUITE # 30
OMAHA NE
68114-3457
US

IV. Provider business mailing address

5506 S 104TH CIR
OMAHA NE
68127-3036
US

V. Phone/Fax

Practice location:
  • Phone: 402-354-8797
  • Fax: 402-354-5651
Mailing address:
  • Phone: 402-592-3610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number183
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number183
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: