Provider Demographics
NPI:1346760170
Name:WAGGONER, KRISTA (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 BRAVES WAY
Mailing Address - Street 2:
Mailing Address - City:LAVON
Mailing Address - State:TX
Mailing Address - Zip Code:75166-4700
Mailing Address - Country:US
Mailing Address - Phone:734-620-4533
Mailing Address - Fax:
Practice Address - Street 1:4875 PALM COAST PKWY NW UNIT 2
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-3671
Practice Address - Country:US
Practice Address - Phone:386-446-9935
Practice Address - Fax:386-446-7777
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-22
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX117777235Z00000X
FLSA16585235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSA16585OtherFLORIDA HEALTHCARE PRACTIONER LICENSE
FLSZ8087OtherFLORIDA HEALTHCARE PRACTIONER LICENSE
TX117777OtherTEXAS SPEECH-LANGUAGE PATHOLOGIST LICENSE