Provider Demographics
NPI:1720438963
Name:WAGONER, LISA CARROLL (RN, COHN-S)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:CARROLL
Last Name:WAGONER
Suffix:
Gender:F
Credentials:RN, COHN-S
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:HARGETT
Other - Last Name:WAGONER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN, BSN
Mailing Address - Street 1:5444 FULLERTON CIR
Mailing Address - Street 2:
Mailing Address - City:HIGHLANDS RANCH
Mailing Address - State:CO
Mailing Address - Zip Code:80130-6642
Mailing Address - Country:US
Mailing Address - Phone:910-409-8509
Mailing Address - Fax:
Practice Address - Street 1:5444 FULLERTON CIR
Practice Address - Street 2:
Practice Address - City:HIGHLANDS RANCH
Practice Address - State:CO
Practice Address - Zip Code:80130-6642
Practice Address - Country:US
Practice Address - Phone:910-409-8509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-19
Last Update Date:2016-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN.1632465163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator