Individual
KELLY ANN WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
RD
Contact information
Practice address
3530 N RETA AVE APT 2R, CHICAGO, IL 60657-6912
(630) 776-5461
Mailing address
3530 N RETA AVE APT 2R, CHICAGO, IL 60657-6912
(630) 776-5461
Taxonomy
Speciality
Code
Description
License number
State
133V00000X
Registered Dietitian
Primary
164.007063
IL
133V00000X
Registered Dietitian
L006355
NC
Other
Enumeration date
03/18/2021
Last updated
03/18/2021
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