Basic Information
| Provider Information | |||||||||
| NPI: | 1235492570 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | KAYLA | ||||||||
| MiddleName: | ROSE | ||||||||
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| Credential: | RD, LD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 712 S CASCADE ST | ||||||||
| Address2: | |||||||||
| City: | FERGUS FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565372913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187368000 | ||||||||
| FaxNumber: | 2187368719 | ||||||||
| Practice Location | |||||||||
| Address1: | 712 S CASCADE ST | ||||||||
| Address2: | |||||||||
| City: | FERGUS FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565372913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187368000 | ||||||||
| FaxNumber: | 2187368719 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2012 | ||||||||
| LastUpdateDate: | 08/21/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 3119 | MN | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 10050503 | 01 | MN | SERVSAFE | OTHER | 3119 | 01 | MN | BOARD OF DIETETICS & NUTRITION PRACTICE | OTHER | XE20265137 | 01 | NATIONAL REGISTRY OF FOOD SAFETY CERTIFIED FOOD SAFETY MANAGER | OTHER | 86007314 | 01 | MN | ACADEMY OF NUTRITION AND DIETETICS VERIFICATION | OTHER |