Provider Demographics
NPI:1598033227
Name:WAGGONER, CHRISTINE RANKIN (FNP-C)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:RANKIN
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:
Other - Last Name:MCARTHUR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:126 SYCAMORE RDG
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-7069
Mailing Address - Country:US
Mailing Address - Phone:601-899-2874
Mailing Address - Fax:
Practice Address - Street 1:126 SYCAMORE RDG
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-7069
Practice Address - Country:US
Practice Address - Phone:601-899-2874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-08
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR852672363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09228771Medicaid
MS333540YX1DMedicare PIN