Healthcare Provider Details

I. General information

NPI: 1295699734
Provider Name (Legal Business Name): KRISTEN ANNETTE WAGUESPACK MS,RD,LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2025
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 RIVER RD
JEFFERSON LA
70121-4227
US

IV. Provider business mailing address

101 THERIOT LN
THIBODAUX LA
70301-6711
US

V. Phone/Fax

Practice location:
  • Phone: 504-203-8620
  • Fax:
Mailing address:
  • Phone: 985-790-2888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1301X
TaxonomyOncology Nutrition Registered Dietitian
License Number3265
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: