Provider Demographics
NPI:1720724958
Name:WAGGONER, BETHANY JANE
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:JANE
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 1:5865 STATE ROUTE 464
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42066-4551
Mailing Address - Country:US
Mailing Address - Phone:270-705-0314
Mailing Address - Fax:
Practice Address - Street 1:100 W RAMSEY ST
Practice Address - Street 2:
Practice Address - City:DAWSON SPRINGS
Practice Address - State:KY
Practice Address - Zip Code:42408-1739
Practice Address - Country:US
Practice Address - Phone:813-227-0797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-10
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
KY277629235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist