Provider Demographics
NPI:1376755488
Name:WAGGONER, FIDELA (RN)
Entity Type:Individual
Prefix:MS
First Name:FIDELA
Middle Name:
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12530 OUT OF THE WAY PLACE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95603-2927
Mailing Address - Country:US
Mailing Address - Phone:530-305-8048
Mailing Address - Fax:
Practice Address - Street 1:12530 OUT OF THE WAY PLACE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-2927
Practice Address - Country:US
Practice Address - Phone:530-305-8048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA352490163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA352490OtherREGISTERED NURSE
CARVN003000OtherPROVIDER NUMBER