Provider Demographics
NPI:1669140604
Name:WAGONER, KAYLA RILEY (PTA)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:RILEY
Last Name:WAGONER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 FLETCHER ST
Mailing Address - Street 2:
Mailing Address - City:WILKESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28697-9472
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1016 FLETCHER ST
Practice Address - Street 2:
Practice Address - City:WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28697-9472
Practice Address - Country:US
Practice Address - Phone:336-667-9261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-03
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant