Provider Demographics
NPI:1033003116
Name:WAGONER, MALLORI JANE
Entity type:Individual
Prefix:MISS
First Name:MALLORI
Middle Name:JANE
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 1:21 INDIAN HILLS RD
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-4843
Mailing Address - Country:US
Mailing Address - Phone:402-679-2834
Mailing Address - Fax:
Practice Address - Street 1:2724 AVENUE B
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51501-2106
Practice Address - Country:US
Practice Address - Phone:402-679-2834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-04
Last Update Date:2025-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant