Provider Demographics
NPI:1801229893
Name:WAGONER, KAYLA ELLEN (DC)
Entity Type:Individual
Prefix:DR
First Name:KAYLA
Middle Name:ELLEN
Last Name:WAGONER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:KAYLA
Other - Middle Name:ELLEN
Other - Last Name:ROYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:454 ROLLING RIDGE DR
Mailing Address - Street 2:SUITE 4
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801-7696
Mailing Address - Country:US
Mailing Address - Phone:814-954-4182
Mailing Address - Fax:
Practice Address - Street 1:454 ROLLING RIDGE DR
Practice Address - Street 2:SUITE 4
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-7696
Practice Address - Country:US
Practice Address - Phone:814-954-4182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-14
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC010874111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor