Provider Demographics
NPI:1780092338
Name:VAN WAGENEN, KATHERINE NICOLE (DC)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:NICOLE
Last Name:VAN WAGENEN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 APOLLO STREET
Mailing Address - Street 2:SUITE A
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77058-2672
Mailing Address - Country:US
Mailing Address - Phone:281-286-2229
Mailing Address - Fax:281-727-0453
Practice Address - Street 1:900 APOLLO STREET
Practice Address - Street 2:SUITE A
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77058-2672
Practice Address - Country:US
Practice Address - Phone:281-286-2229
Practice Address - Fax:281-727-0453
Is Sole Proprietor?:No
Enumeration Date:2014-07-28
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12705111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor