Provider Demographics
NPI:1255903621
Name:WAGGONER, EMILY ANNE
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:ANNE
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1810 MARLANDWOOD RD APT 9208
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502-2809
Mailing Address - Country:US
Mailing Address - Phone:812-508-9644
Mailing Address - Fax:
Practice Address - Street 1:7901 METROPOLIS DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78744-3111
Practice Address - Country:US
Practice Address - Phone:254-743-1786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered