Provider Demographics
NPI:1891295549
Name:WAGGONER, MACKENZIE ANN (PT)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:ANN
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:PT
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 306556
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37230-6556
Mailing Address - Country:US
Mailing Address - Phone:615-329-2294
Mailing Address - Fax:615-695-1494
Practice Address - Street 1:1035 S HARTMANN DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37090-4064
Practice Address - Country:US
Practice Address - Phone:615-321-3310
Practice Address - Fax:615-443-5488
Is Sole Proprietor?:No
Enumeration Date:2018-02-20
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12258225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist