Provider Demographics
NPI:1154730364
Name:KING, WANDA L (MS, RDN, CLC)
Entity type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:L
Last Name:KING
Suffix:
Gender:F
Credentials:MS, RDN, CLC
Other - Prefix:
Other - First Name:WANDA
Other - Middle Name:
Other - Last Name:WILDENBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, RDN, CLC
Mailing Address - Street 1:PO BOX 1010
Mailing Address - Street 2:
Mailing Address - City:POLSON
Mailing Address - State:MT
Mailing Address - Zip Code:59860-1010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6 THIRTEENTH AVENUE EAST
Practice Address - Street 2:
Practice Address - City:POSLON
Practice Address - State:MT
Practice Address - Zip Code:59860
Practice Address - Country:US
Practice Address - Phone:406-883-8454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-13
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-NUTR-LIC-581133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered