Provider Demographics
NPI:1689793218
Name:WAGONER, LYNN
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:
Last Name:WAGONER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3503 KIRBY DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27403-1020
Mailing Address - Country:US
Mailing Address - Phone:336-852-2081
Mailing Address - Fax:
Practice Address - Street 1:2300 SPRING GARDEN ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27403-2135
Practice Address - Country:US
Practice Address - Phone:336-294-3338
Practice Address - Fax:336-294-6696
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner