Provider Demographics
NPI:1730547274
Name:WAGNER, PAMELA (RD)
Entity type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2134 HANDEL AVE
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-5723
Mailing Address - Country:US
Mailing Address - Phone:702-860-8547
Mailing Address - Fax:
Practice Address - Street 1:2134 HANDEL AVE
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-5723
Practice Address - Country:US
Practice Address - Phone:702-860-8547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-28
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV32901DI-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered