Provider Demographics
NPI:1215059142
Name:WAGGONER, CASSANDRA JOAN
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:JOAN
Last Name:WAGGONER
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 1:10318 6TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-8116
Mailing Address - Country:US
Mailing Address - Phone:701-238-3908
Mailing Address - Fax:701-232-2330
Practice Address - Street 1:10318 6TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-8116
Practice Address - Country:US
Practice Address - Phone:701-238-3908
Practice Address - Fax:701-232-2330
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND974235Z00000X
MN429103235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist