Provider Demographics
NPI:1437562741
Name:WAGGONER, TERESA CHA (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:CHA
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25115 AVENUE STANFORD, SUITE A-104
Mailing Address - Street 2:
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91355
Mailing Address - Country:US
Mailing Address - Phone:661-257-2339
Mailing Address - Fax:661-257-2384
Practice Address - Street 1:23772 NEWHALL AVENUE
Practice Address - Street 2:
Practice Address - City:NEWHALL
Practice Address - State:CA
Practice Address - Zip Code:91321
Practice Address - Country:US
Practice Address - Phone:661-291-1777
Practice Address - Fax:661-255-1208
Is Sole Proprietor?:No
Enumeration Date:2014-06-04
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23178363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily