Individual
KELLI WAGGONNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
8595 MEDICAL CENTER BLVD, PORT ARTHUR, TX 77640-2428
(409) 721-8600
Mailing address
5685 PAT DR, ORANGE, TX 77630-7571
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
212923
TX
Other
Enumeration date
11/11/2019
Last updated
11/11/2019
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