Provider Demographics
NPI:1134267206
Name:BAGNELL, LORI A (RD,LD)
Entity type:Individual
Prefix:MRS
First Name:LORI
Middle Name:A
Last Name:BAGNELL
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 1:12444 SEVEN EAGLES LN
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-7554
Mailing Address - Country:US
Mailing Address - Phone:817-551-5501
Mailing Address - Fax:
Practice Address - Street 1:201 WALLS DR
Practice Address - Street 2:
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76033-4007
Practice Address - Country:US
Practice Address - Phone:817-556-4267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT05893133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered