Provider Demographics
NPI:1275040818
Name:AGNEW, MARY ELIZABETH (RDN)
Entity Type:Individual
Prefix:MISS
First Name:MARY
Middle Name:ELIZABETH
Last Name:AGNEW
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:827 GULLETT ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78702-4125
Mailing Address - Country:US
Mailing Address - Phone:512-517-9156
Mailing Address - Fax:
Practice Address - Street 1:827 GULLETT ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78702-4125
Practice Address - Country:US
Practice Address - Phone:512-517-9156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-04
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.007313133V00000X
TXDT84558133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty