Healthcare Provider Details

I. General information

NPI: 1700708864
Provider Name (Legal Business Name): ANNA GRACE WAGONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 RIVERSIDE DR
MOUNT AIRY NC
27030-3850
US

IV. Provider business mailing address

215 OAK HILL DR
MOUNT AIRY NC
27030-7484
US

V. Phone/Fax

Practice location:
  • Phone: 336-786-8355
  • Fax:
Mailing address:
  • Phone: 336-755-9033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number30003090
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: