Provider Demographics
NPI:1740450741
Name:WAGNER, VONDA KARLA (MA)
Entity type:Individual
Prefix:
First Name:VONDA
Middle Name:KARLA
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1167 SPRATLIN PARK DR
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-6205
Mailing Address - Country:US
Mailing Address - Phone:423-467-3600
Mailing Address - Fax:423-467-3644
Practice Address - Street 1:2243 EDDIE WILLIAMS RD
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-2872
Practice Address - Country:US
Practice Address - Phone:423-928-5627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-05
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X
TN3674101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other