Provider Demographics
NPI:1558545707
Name:SHAGINOFF, INGRID DORIS (MS RD LN)
Entity Type:Individual
Prefix:MS
First Name:INGRID
Middle Name:DORIS
Last Name:SHAGINOFF
Suffix:
Gender:F
Credentials:MS RD LN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 E INDUSTRIAL DR
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-8201
Mailing Address - Country:US
Mailing Address - Phone:907-357-3003
Mailing Address - Fax:907-357-3003
Practice Address - Street 1:2000 E INDUSTRIAL DR
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-8201
Practice Address - Country:US
Practice Address - Phone:907-357-3003
Practice Address - Fax:907-357-3003
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-24
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2133NN1002X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADT00022Medicaid