Provider Demographics
NPI:1336730977
Name:WAGGONER, LAKEN (NP)
Entity Type:Individual
Prefix:
First Name:LAKEN
Middle Name:
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1689 SMOKE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-3489
Mailing Address - Country:US
Mailing Address - Phone:812-583-8256
Mailing Address - Fax:
Practice Address - Street 1:1625 MEDICAL CENTER PT STE 100
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-5798
Practice Address - Country:US
Practice Address - Phone:719-576-4744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-27
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COC-APN.0002303-C-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner