Provider Demographics
NPI:1881817427
Name:WAGGONER, CYNTHIA K (RN)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:K
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 PAGEANT LN
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-3854
Mailing Address - Country:US
Mailing Address - Phone:931-648-5747
Mailing Address - Fax:931-645-9019
Practice Address - Street 1:650 JOEL DR
Practice Address - Street 2:
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5318
Practice Address - Country:US
Practice Address - Phone:270-956-0118
Practice Address - Fax:270-956-0118
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN92160163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN92160OtherRN