Provider Demographics
NPI:1245943166
Name:BAGWELL, REBECCA (RDN, LDN)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:BAGWELL
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:STILES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7731 OLD CANTON RD STE B
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6115
Mailing Address - Country:US
Mailing Address - Phone:601-499-0935
Mailing Address - Fax:
Practice Address - Street 1:7730 OLD CANTON RD BLDG A
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-9299
Practice Address - Country:US
Practice Address - Phone:601-499-0935
Practice Address - Fax:601-499-0936
Is Sole Proprietor?:No
Enumeration Date:2023-01-05
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered