Healthcare Provider Details

I. General information

NPI: 1801557897
Provider Name (Legal Business Name): FARRIS ASHLEY RAE WAGGONER PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: FARRIS ASHLEY RAE PT, DPT

II. Dates (important events)

Enumeration Date: 01/03/2022
Last Update Date: 01/03/2022
Certification Date: 12/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20818 44TH AVE W STE 270-P
LYNNWOOD WA
98036-7709
US

IV. Provider business mailing address

1220 6TH AVE S APT B201
EDMONDS WA
98020-4635
US

V. Phone/Fax

Practice location:
  • Phone: 425-672-2716
  • Fax: 425-672-2720
Mailing address:
  • Phone: 425-749-2227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT61149357
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: