Provider Demographics
NPI:1407962293
Name:WAGGONER, RENEE COLLETTE (MS RD LD)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:COLLETTE
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:MS RD LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 LONE OAK RD
Mailing Address - Street 2:PO BOX 7100
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-7901
Mailing Address - Country:US
Mailing Address - Phone:270-444-2909
Mailing Address - Fax:270-444-2977
Practice Address - Street 1:1530 LONE OAK RD
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-7901
Practice Address - Country:US
Practice Address - Phone:270-444-2909
Practice Address - Fax:270-444-2977
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-0158133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered