Healthcare Provider Details

I. General information

NPI: 1194794271
Provider Name (Legal Business Name): AMY JEANNETTE WAGGONER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 03/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CVS DR MAIL CODE 3005
WOONSOCKET RI
02895-6146
US

IV. Provider business mailing address

7206 EGANHILL DR
AUSTIN TX
78745-5114
US

V. Phone/Fax

Practice location:
  • Phone: 512-791-6564
  • Fax:
Mailing address:
  • Phone: 512-791-6564
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number617781
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: