Provider Demographics
NPI:1558637496
Name:WAGGONER, ANNA ELIZABETH (LMT)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:ELIZABETH
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5869 NASH LN
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46224-5308
Mailing Address - Country:US
Mailing Address - Phone:317-728-8121
Mailing Address - Fax:
Practice Address - Street 1:5869 NASH LN
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46224-5308
Practice Address - Country:US
Practice Address - Phone:317-728-8121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-26
Last Update Date:2012-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT21104026171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor