Provider Demographics
NPI:1497843296
Name:WAGONER, ERICA Y (LMP)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:Y
Last Name:WAGONER
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4208 MEADOWVIEW DR
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-9523
Mailing Address - Country:US
Mailing Address - Phone:509-543-9224
Mailing Address - Fax:
Practice Address - Street 1:552 N COLORADO ST
Practice Address - Street 2:STE. 200
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-7779
Practice Address - Country:US
Practice Address - Phone:509-736-6060
Practice Address - Fax:509-736-3939
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00016506225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist