Provider Demographics
NPI:1497343271
Name:WAGONER, CHARLOTTE BONITA
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:BONITA
Last Name:WAGONER
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:PO BOX 356
Mailing Address - Street 2:
Mailing Address - City:FORT ASHBY
Mailing Address - State:WV
Mailing Address - Zip Code:26719-0356
Mailing Address - Country:US
Mailing Address - Phone:304-298-4990
Mailing Address - Fax:304-788-6363
Practice Address - Street 1:40 CEDAR LANE
Practice Address - Street 2:
Practice Address - City:FORT ASHBY
Practice Address - State:WV
Practice Address - Zip Code:26719
Practice Address - Country:US
Practice Address - Phone:304-298-4990
Practice Address - Fax:304-788-6363
Is Sole Proprietor?:No
Enumeration Date:2021-01-06
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant