Healthcare Provider Details

I. General information

NPI: 1366308009
Provider Name (Legal Business Name): WANDA JEAN MATUSZAK MS,RD,LD,CNSC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2025
Last Update Date: 12/26/2025
Certification Date: 12/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 CAMINO DE SALUD NE
ALBUQUERQUE NM
87102-4517
US

IV. Provider business mailing address

3924 LAS COLINAS AVE NE
RIO RANCHO NM
87124-4393
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-4946
  • Fax:
Mailing address:
  • Phone: 505-272-4946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1301X
TaxonomyOncology Nutrition Registered Dietitian
License NumberLD-0674
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: