Provider Demographics
NPI:1619482015
Name:WAGGONER, LACY JAYE (LMT)
Entity Type:Individual
Prefix:
First Name:LACY
Middle Name:JAYE
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 1:200 OAKLAND ST
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:MO
Mailing Address - Zip Code:64473-9200
Mailing Address - Country:US
Mailing Address - Phone:660-446-2650
Mailing Address - Fax:
Practice Address - Street 1:601 E NODAWAY ST
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:MO
Practice Address - Zip Code:64473-9602
Practice Address - Country:US
Practice Address - Phone:660-572-0433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-06
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013033098225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist