Healthcare Provider Details

I. General information

NPI: 1770823759
Provider Name (Legal Business Name): KRISTINA L WAGGONER PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2013
Last Update Date: 05/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 NORTH DICKINSON DRIVE
RUSK TX
75785
US

IV. Provider business mailing address

805 NORTH DICKINSON DRIVE
RUSK TX
75785
US

V. Phone/Fax

Practice location:
  • Phone: 903-683-7201
  • Fax: 903-683-7199
Mailing address:
  • Phone: 903-683-7201
  • Fax: 903-683-7199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number763777
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: