Provider Demographics
NPI:1376342204
Name:WAGONER, LISA C
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:C
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 1:17 EVANS ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:NJ
Mailing Address - Zip Code:07416-1419
Mailing Address - Country:US
Mailing Address - Phone:973-534-5855
Mailing Address - Fax:
Practice Address - Street 1:17 EVANS ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:NJ
Practice Address - Zip Code:07416-1419
Practice Address - Country:US
Practice Address - Phone:973-534-5855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-12
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT00679200225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty