Provider Demographics
NPI:1184279309
Name:WAGNON, MADELINE (MS, CFY-SLP)
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:WAGNON
Suffix:
Gender:F
Credentials:MS, CFY-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2580 E JOYCE BLVD STE 12
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-3924
Mailing Address - Country:US
Mailing Address - Phone:479-521-7337
Mailing Address - Fax:479-521-7338
Practice Address - Street 1:2580 E JOYCE BLVD STE 12
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-3924
Practice Address - Country:US
Practice Address - Phone:479-521-7337
Practice Address - Fax:479-521-7338
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-05
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist