Provider Demographics
NPI:1770823759
Name:WAGGONER, KRISTINA L (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:L
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 NORTH DICKINSON DRIVE
Mailing Address - Street 2:
Mailing Address - City:RUSK
Mailing Address - State:TX
Mailing Address - Zip Code:75785
Mailing Address - Country:US
Mailing Address - Phone:903-683-7201
Mailing Address - Fax:903-683-7199
Practice Address - Street 1:805 NORTH DICKINSON DRIVE
Practice Address - Street 2:
Practice Address - City:RUSK
Practice Address - State:TX
Practice Address - Zip Code:75785
Practice Address - Country:US
Practice Address - Phone:903-683-7201
Practice Address - Fax:903-683-7199
Is Sole Proprietor?:No
Enumeration Date:2013-02-27
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX763777363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX763777OtherSTATE LICENSE