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General NPI Number Information
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NPI Number | 1396454484
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Entity Type | Organization
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Legal Business Name | WAGONER HEALTH CLINIC, PLLC
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Dates
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Enumeration Date | 11/17/2022
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Last Update Date | 12/19/2022
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Provider Practice Location Address
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Address Line | 1023 N MOUND ST STE E
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City | NACOGDOCHES
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State | TX
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Zip | 75961-4453
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Country | US
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Telephone | 936-305-4130
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Fax | 936-305-4127
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Provider Business Mailing Address
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Address Line | 1023 N MOUND ST STE E
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City | NACOGDOCHES
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State | TX
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Zip | 75961-4453
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Country | US
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Telephone | 936-305-4130
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Fax | 936-305-4127
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | MRS. REBEKAH M WAGONER
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Credential | APRN, FNP-C
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Telephone | 936-715-5353
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP2300X
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Taxonomy Name | Primary Care Nurse Practitioner
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License Number |
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License Number State |
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