Provider Demographics
NPI:1457074502
Name:WAGGONER, MYLA
Entity Type:Individual
Prefix:
First Name:MYLA
Middle Name:
Last Name:WAGGONER
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 1:317 DUTCH RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26104-7133
Mailing Address - Country:US
Mailing Address - Phone:681-315-0022
Mailing Address - Fax:
Practice Address - Street 1:1222 MARKET ST
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101-4323
Practice Address - Country:US
Practice Address - Phone:304-865-5420
Practice Address - Fax:304-465-0886
Is Sole Proprietor?:No
Enumeration Date:2022-09-23
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker