Healthcare Provider Details

I. General information

NPI: 1497149397
Provider Name (Legal Business Name): ALLISON L WAGGONER D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2015
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 HARTFORD TPKE STE 210
VERNON CT
06066-4841
US

IV. Provider business mailing address

428 HARTFORD TPKE STE 210
VERNON CT
06066-4841
US

V. Phone/Fax

Practice location:
  • Phone: 860-533-4611
  • Fax: 860-871-5927
Mailing address:
  • Phone: 860-533-4611
  • Fax: 860-871-5927

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number60561
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: