Provider Demographics
NPI:1386903771
Name:WAGONER, LISA JANE (MHPP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:JANE
Last Name:WAGONER
Suffix:
Gender:F
Credentials:MHPP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:JANE
Other - Last Name:SNOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MHPP
Mailing Address - Street 1:316 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLAGE
Mailing Address - State:AR
Mailing Address - Zip Code:71653-1942
Mailing Address - Country:US
Mailing Address - Phone:870-265-2186
Mailing Address - Fax:870-265-2305
Practice Address - Street 1:316 MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKE VILLAGE
Practice Address - State:AR
Practice Address - Zip Code:71653-1942
Practice Address - Country:US
Practice Address - Phone:870-265-2186
Practice Address - Fax:870-265-2305
Is Sole Proprietor?:No
Enumeration Date:2012-05-07
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator