Provider Demographics
NPI:1679727358
Name:WAGGONER, LONI (LMP)
Entity Type:Individual
Prefix:
First Name:LONI
Middle Name:
Last Name:WAGGONER
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:PO BOX 1239
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83816-1239
Mailing Address - Country:US
Mailing Address - Phone:208-667-9839
Mailing Address - Fax:208-765-6169
Practice Address - Street 1:101 W 8TH AVE
Practice Address - Street 2:SUITE 1300
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2307
Practice Address - Country:US
Practice Address - Phone:509-474-2444
Practice Address - Fax:506-474-2443
Is Sole Proprietor?:No
Enumeration Date:2008-11-08
Last Update Date:2008-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00024282172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist