Provider Demographics
NPI:1710670914
Name:WAGSTAFF, EMMA GRACE (RD)
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:GRACE
Last Name:WAGSTAFF
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3781 S FOREST HILLS DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-4208
Mailing Address - Country:US
Mailing Address - Phone:801-558-8281
Mailing Address - Fax:
Practice Address - Street 1:45 W 9000 S STE 1
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-2047
Practice Address - Country:US
Practice Address - Phone:801-558-8281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT86294476133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered