Healthcare Provider Details

I. General information

NPI: 1891939344
Provider Name (Legal Business Name): BLAIR ELLEN WAGONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2009
Last Update Date: 04/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 MONARCH ST SUITE 110
LEXINGTON KY
40513-1495
US

IV. Provider business mailing address

115 WEST DR
MURRAY KY
42071-9830
US

V. Phone/Fax

Practice location:
  • Phone: 859-224-0834
  • Fax:
Mailing address:
  • Phone: 270-293-0758
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 3141
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT005412
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: