Provider Demographics
NPI:1033388624
Name:WAGGONER, MARY HELEN (LMP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:HELEN
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4210 20TH ST E
Mailing Address - Street 2:STE D
Mailing Address - City:FIFE
Mailing Address - State:WA
Mailing Address - Zip Code:98424-1830
Mailing Address - Country:US
Mailing Address - Phone:253-922-0450
Mailing Address - Fax:253-926-1720
Practice Address - Street 1:4210 20TH ST E
Practice Address - Street 2:STE D
Practice Address - City:FIFE
Practice Address - State:WA
Practice Address - Zip Code:98424-1830
Practice Address - Country:US
Practice Address - Phone:253-922-0450
Practice Address - Fax:253-926-1720
Is Sole Proprietor?:No
Enumeration Date:2008-02-27
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00023466225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist