Healthcare Provider Details

I. General information

NPI: 1649013772
Provider Name (Legal Business Name): ALISHIA ANN WAGGONER FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2024
Last Update Date: 08/27/2025
Certification Date: 08/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 N PENNSYLVANIA AVE
INDEPENDENCE KS
67301-2222
US

IV. Provider business mailing address

PO BOX 1832
PITTSBURG KS
66762-1832
US

V. Phone/Fax

Practice location:
  • Phone: 620-331-2400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number53-83284-031
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: