Healthcare Provider Details

I. General information

NPI: 1376453431
Provider Name (Legal Business Name): MAKENNA JANE STAGGERS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3921 ROGER HAYNES DR
CASTLE HAYNE NC
28429-5681
US

IV. Provider business mailing address

1221 PATTISON ST
WILMINGTON NC
28412-6127
US

V. Phone/Fax

Practice location:
  • Phone: 910-602-4046
  • Fax:
Mailing address:
  • Phone: 304-813-0171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number30005619
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: