Provider Demographics
NPI:1447802228
Name:WAGGONER, NANCY
Entity Type:Individual
Prefix:
First Name:NANCY
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 1:1710 W THOMPSON AVE
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-7727
Mailing Address - Country:US
Mailing Address - Phone:580-242-2970
Mailing Address - Fax:
Practice Address - Street 1:1710 W THOMPSON AVE
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-7727
Practice Address - Country:US
Practice Address - Phone:580-242-2970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-12
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)