Healthcare Provider Details

I. General information

NPI: 1447764535
Provider Name (Legal Business Name): TAYLOR LAUREN WAGGONER OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2017
Last Update Date: 11/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 GIBSON BAY DR
RICHMOND KY
40475-3448
US

IV. Provider business mailing address

1020 GIBSON BAY DR
RICHMOND KY
40475-3448
US

V. Phone/Fax

Practice location:
  • Phone: 859-623-3358
  • Fax: 859-623-8141
Mailing address:
  • Phone: 859-623-3358
  • Fax: 859-623-8141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2078DT
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: