Provider Demographics
NPI:1104539071
Name:WAGGNER, ALIYAH
Entity type:Individual
Prefix:
First Name:ALIYAH
Middle Name:
Last Name:WAGGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 SINGLETON BLVD APT 1073
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75212-5305
Mailing Address - Country:US
Mailing Address - Phone:225-938-6238
Mailing Address - Fax:
Practice Address - Street 1:15301 SPECTRUM DR
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-4665
Practice Address - Country:US
Practice Address - Phone:972-661-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-05
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1105759363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily