Provider Demographics
NPI:1447225289
Name:WAGGONER, JULIE ANN (CPNP,ARNP)
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:ANN
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:CPNP,ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2555 BERKSHIRE PKWY
Mailing Address - Street 2:
Mailing Address - City:CLIVE
Mailing Address - State:IA
Mailing Address - Zip Code:50325-4646
Mailing Address - Country:US
Mailing Address - Phone:515-987-0051
Mailing Address - Fax:515-987-0054
Practice Address - Street 1:2555 BERKSHIRE PKWY
Practice Address - Street 2:
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-4646
Practice Address - Country:US
Practice Address - Phone:515-987-0051
Practice Address - Fax:515-987-0054
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2016-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAC-078227363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0478958Medicaid