Provider Demographics
NPI:1235383811
Name:AGNOR, WANDA S
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:S
Last Name:AGNOR
Suffix:
Gender:F
Credentials:
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 765
Mailing Address - Street 2:1565 NORTH LEE HIGHWAY
Mailing Address - City:LEXINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:24450-0765
Mailing Address - Country:US
Mailing Address - Phone:540-464-9663
Mailing Address - Fax:540-464-9668
Practice Address - Street 1:1565 N LEE HWY
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:VA
Practice Address - Zip Code:24450-3301
Practice Address - Country:US
Practice Address - Phone:540-464-9663
Practice Address - Fax:540-464-9668
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-10
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA79422008174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist