Healthcare Provider Details

I. General information

NPI: 1699019117
Provider Name (Legal Business Name): KELSEY WAGONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2012
Last Update Date: 06/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 S GARDEN WAY APT 9
EUGENE OR
97401-5909
US

IV. Provider business mailing address

101 S GARDEN WAY APT 9
EUGENE OR
97401-5909
US

V. Phone/Fax

Practice location:
  • Phone: 503-312-9800
  • Fax:
Mailing address:
  • Phone: 503-312-9800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: