Provider Demographics
NPI:1427639301
Name:WAGGONER, BONNY JEAN (FNP)
Entity type:Individual
Prefix:
First Name:BONNY
Middle Name:JEAN
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:BONNY
Other - Middle Name:JEAN
Other - Last Name:WORLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13570 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:GA
Mailing Address - Zip Code:30752-2012
Mailing Address - Country:US
Mailing Address - Phone:706-956-2665
Mailing Address - Fax:706-956-2665
Practice Address - Street 1:701 E EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-2833
Practice Address - Country:US
Practice Address - Phone:650-404-8370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-21
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN252583163W00000X
TN29509363LF0000X
CA95026506363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse