Provider Demographics
NPI:1417299447
Name:WAGGONER, SHELLEY
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:WAGGONER
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 1:6727 S 73RD EAST AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-1832
Mailing Address - Country:US
Mailing Address - Phone:918-734-5866
Mailing Address - Fax:
Practice Address - Street 1:6333 E SKELLY DR
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-6106
Practice Address - Country:US
Practice Address - Phone:918-633-2442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-16
Last Update Date:2013-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist