Basic Information
| Provider Information | |||||||||
| NPI: | 1073163713 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WAGONER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4660 KENMORE AVE STE 409 | ||||||||
| Address2: | |||||||||
| City: | ALEXANDRIA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 223041306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038233336 | ||||||||
| FaxNumber: | 7038234684 | ||||||||
| Practice Location | |||||||||
| Address1: | 4660 KENMORE AVE STE 409 | ||||||||
| Address2: | |||||||||
| City: | ALEXANDRIA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 223041306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038233336 | ||||||||
| FaxNumber: | 7038234684 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2019 | ||||||||
| LastUpdateDate: | 09/15/2019 | ||||||||
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| AuthorizedOfficialLastName: | WAGONER | ||||||||
| AuthorizedOfficialFirstName: | JULIE | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/AUD | ||||||||
| AuthorizedOfficialTelephone: | 7038233336 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | AUD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
No ID Information.