Provider Demographics
NPI:1730730912
Name:WAGONER, KRISTINA S
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:S
Last Name:WAGONER
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 1:6651 CHULA VISTA CT
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89436-9148
Mailing Address - Country:US
Mailing Address - Phone:775-343-8589
Mailing Address - Fax:
Practice Address - Street 1:3100 MILL ST STE 213
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-2259
Practice Address - Country:US
Practice Address - Phone:775-343-8589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-27
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst