Provider Demographics
NPI:1215045612
Name:WAGGONER, PEGGY ELLEN (MA)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:ELLEN
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9418
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77387-9418
Mailing Address - Country:US
Mailing Address - Phone:866-249-9736
Mailing Address - Fax:
Practice Address - Street 1:3901 RAINBOW BLVD MSC 4043
Practice Address - Street 2:2032 SCHOOL OF NURSING
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66160-0001
Practice Address - Country:US
Practice Address - Phone:866-249-9736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-26
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS952235Z00000X
MO107658235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200365490AMedicaid
14084038OtherIND BCBS PROVIDER NUMBER