Provider Demographics
NPI:1265951081
Name:WAGGONER, LAUREN MICHELE (PT, DPT)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:MICHELE
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 PARK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-2290
Mailing Address - Country:US
Mailing Address - Phone:704-323-3611
Mailing Address - Fax:704-945-7681
Practice Address - Street 1:710 PARK CENTER DR STE 200
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-5082
Practice Address - Country:US
Practice Address - Phone:043-233-2087
Practice Address - Fax:704-323-3240
Is Sole Proprietor?:No
Enumeration Date:2017-09-13
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9386225100000X
NCP22641225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist