Provider Demographics
NPI:1194837534
Name:WAGGONER, GRETCHEN LYNNETTE (AUD)
Entity Type:Individual
Prefix:MRS
First Name:GRETCHEN
Middle Name:LYNNETTE
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14987 STATE RD
Mailing Address - Street 2:
Mailing Address - City:OSTRANDER
Mailing Address - State:OH
Mailing Address - Zip Code:43061-9508
Mailing Address - Country:US
Mailing Address - Phone:740-666-0004
Mailing Address - Fax:
Practice Address - Street 1:456 W 10TH AVE
Practice Address - Street 2:4A
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1240
Practice Address - Country:US
Practice Address - Phone:614-293-8065
Practice Address - Fax:614-293-6179
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHA01097231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist