Provider Demographics
NPI:1770969750
Name:WAGNER, TERESA (RD, LD)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11056 EAGLE VIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-5223
Mailing Address - Country:US
Mailing Address - Phone:651-387-1873
Mailing Address - Fax:
Practice Address - Street 1:45 SNELLING AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-6842
Practice Address - Country:US
Practice Address - Phone:651-699-3438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-03
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3574133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered