Provider Demographics
NPI:1366001018
Name:WAGGY, JOHANNE MAE (NP)
Entity Type:Individual
Prefix:
First Name:JOHANNE
Middle Name:MAE
Last Name:WAGGY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9554 SUNNYSLOPE DR
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20112-2735
Mailing Address - Country:US
Mailing Address - Phone:703-475-9591
Mailing Address - Fax:
Practice Address - Street 1:3251 OLD LEE HWY STE 200
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-1504
Practice Address - Country:US
Practice Address - Phone:877-868-4827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-06
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024177230363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology