Provider Demographics
NPI:1932205242
Name:WAGNER, STACY L (RD LD)
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:L
Last Name:WAGNER
Suffix:
Gender:F
Credentials:RD LD
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 6175
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77342-6175
Mailing Address - Country:US
Mailing Address - Phone:936-291-1153
Mailing Address - Fax:
Practice Address - Street 1:110 MEMORIAL HOSPITAL DR.
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:TX
Practice Address - Zip Code:77340
Practice Address - Country:US
Practice Address - Phone:936-291-4525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT04058133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered