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General NPI Number Information
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NPI Number | 1134302565
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Entity Type | Individual
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Provider Name | ELIZABETH WAGNER RD, CCN
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Gender | Female
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Dates
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Enumeration Date | 12/07/2007
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Last Update Date | 04/01/2011
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Provider Practice Location Address
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Address Line | 1224 10TH ST STE 207
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City | CORONADO
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State | CA
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Zip | 92118-3420
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Country | US
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Telephone | 619-437-6600
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Fax | 619-437-6603
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Provider Business Mailing Address
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Address Line | 1224 10TH ST STE 207
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City | CORONADO
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State | CA
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Zip | 92118-3420
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Country | US
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Telephone | 619-437-6600
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Fax | 619-437-6603
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133N00000X
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Taxonomy Name | Nutritionist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number |
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License Number State |
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