Provider Demographics
NPI:1811656051
Name:WAGGONER, VICTORIA LOUISE
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:LOUISE
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 1:1849 LAMAR AVE STE 160
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:TX
Mailing Address - Zip Code:75460-1402
Mailing Address - Country:US
Mailing Address - Phone:903-401-5311
Mailing Address - Fax:903-401-5312
Practice Address - Street 1:612 E DUKE ST
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:OK
Practice Address - Zip Code:74743-4015
Practice Address - Country:US
Practice Address - Phone:580-326-2200
Practice Address - Fax:903-401-5312
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-15
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251B00000XAgenciesCase Management