Provider Demographics
NPI:1083979264
Name:WAGGONER, MARY ROSE (QMHA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ROSE
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:QMHA
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ROSE
Other - Last Name:KOERNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1121
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-0254
Mailing Address - Country:US
Mailing Address - Phone:541-672-2691
Mailing Address - Fax:
Practice Address - Street 1:621 W MADRONE ST
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-3090
Practice Address - Country:US
Practice Address - Phone:541-440-3532
Practice Address - Fax:541-440-3554
Is Sole Proprietor?:No
Enumeration Date:2012-07-12
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500663428Medicaid