Provider Demographics
NPI:1689498115
Name:ZAGRODNIK, AMANDA (CNS)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:ZAGRODNIK
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1843
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53008-1843
Mailing Address - Country:US
Mailing Address - Phone:262-215-6788
Mailing Address - Fax:
Practice Address - Street 1:10341 W VERA AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53224-4441
Practice Address - Country:US
Practice Address - Phone:262-215-6788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-12
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18998133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist