Provider Demographics
NPI:1952529083
Name:WAGGONER, CAROLINE MADY (LMP)
Entity Type:Individual
Prefix:MRS
First Name:CAROLINE
Middle Name:MADY
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 162
Mailing Address - Street 2:
Mailing Address - City:MERCER ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98040-0162
Mailing Address - Country:US
Mailing Address - Phone:206-328-3164
Mailing Address - Fax:
Practice Address - Street 1:1222 SUMMIT AVE
Practice Address - Street 2:# 307
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-4239
Practice Address - Country:US
Practice Address - Phone:206-328-3164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00021632225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist