Provider Demographics
NPI:1487856548
Name:WAGGONER, TRACY LEE (MPT)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:LEE
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 N ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:ROBINSON
Mailing Address - State:IL
Mailing Address - Zip Code:62454-1167
Mailing Address - Country:US
Mailing Address - Phone:618-546-2695
Mailing Address - Fax:
Practice Address - Street 1:609 N PLEASANT ST
Practice Address - Street 2:
Practice Address - City:HUTSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62433-1119
Practice Address - Country:US
Practice Address - Phone:618-563-9395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist