Provider Demographics
NPI:1285369249
Name:WAGONER, HANNA (RD)
Entity type:Individual
Prefix:
First Name:HANNA
Middle Name:
Last Name:WAGONER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:HANNA
Other - Middle Name:
Other - Last Name:BRAUBURGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2504 S BARCLIFF AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-3533
Mailing Address - Country:US
Mailing Address - Phone:479-586-8246
Mailing Address - Fax:
Practice Address - Street 1:3801 S NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5210
Practice Address - Country:US
Practice Address - Phone:417-269-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-22
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO86290703133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered