Provider Demographics
NPI:1194004689
Name:WAGGONER, SHAELI (DC)
Entity Type:Individual
Prefix:DR
First Name:SHAELI
Middle Name:
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6830 JUNEBERRY AVE
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-1707
Mailing Address - Country:US
Mailing Address - Phone:563-320-5670
Mailing Address - Fax:
Practice Address - Street 1:6830 JUNEBERRY AVE
Practice Address - Street 2:
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-1707
Practice Address - Country:US
Practice Address - Phone:563-320-5670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-15
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038010540111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor