Provider Demographics
NPI:1164238804
Name:WAGSTAFF, ANNA SHUMWAY (RD)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:SHUMWAY
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 1:2418 STOCKTON DR
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-2142
Mailing Address - Country:US
Mailing Address - Phone:314-737-3009
Mailing Address - Fax:
Practice Address - Street 1:2418 STOCKTON DR
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-2142
Practice Address - Country:US
Practice Address - Phone:314-737-3009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-07
Last Update Date:2024-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered