Provider Demographics
NPI:1831542190
Name:WAGGONER, PHYLLIS THORNTON (NP-C)
Entity type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:THORNTON
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11271 NUCKOLS RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-5502
Mailing Address - Country:US
Mailing Address - Phone:804-217-8881
Mailing Address - Fax:
Practice Address - Street 1:11271 NUCKOLS RD
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23059-5502
Practice Address - Country:US
Practice Address - Phone:804-217-8881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-21
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024173765363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily