Provider Demographics
NPI:1912284381
Name:VANWAGONER, RICHELLE (MS, ATC, LAT)
Entity Type:Individual
Prefix:
First Name:RICHELLE
Middle Name:
Last Name:VANWAGONER
Suffix:
Gender:F
Credentials:MS, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 N MILITARY TRL
Mailing Address - Street 2:ATHLETIC TRAINING
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33409-2911
Mailing Address - Country:US
Mailing Address - Phone:561-681-7931
Mailing Address - Fax:561-681-7968
Practice Address - Street 1:2600 N MILITARY TRL
Practice Address - Street 2:ATHLETIC TRAINING
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33409-2911
Practice Address - Country:US
Practice Address - Phone:561-681-7931
Practice Address - Fax:561-681-7968
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-13
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL31142255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer