Provider Demographics
NPI:1629552401
Name:WAGONER, MARCIA LYNN
Entity type:Individual
Prefix:MS
First Name:MARCIA
Middle Name:LYNN
Last Name:WAGONER
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 1:247 COUNTRY CT
Mailing Address - Street 2:
Mailing Address - City:LOOGOOTEE
Mailing Address - State:IN
Mailing Address - Zip Code:47553-5199
Mailing Address - Country:US
Mailing Address - Phone:812-295-6259
Mailing Address - Fax:
Practice Address - Street 1:247 COUNTRY CT
Practice Address - Street 2:
Practice Address - City:LOOGOOTEE
Practice Address - State:IN
Practice Address - Zip Code:47553-5199
Practice Address - Country:US
Practice Address - Phone:812-295-6259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist