Active NPI
Kristina L Waggoner, PMHNP-BC
- Psychiatric/Mental Health Nurse Practitioner
- Rusk, TX
National Provider Identifier
1770823759
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Psychiatric/Mental Health Nurse Practitioner
- License
- 763777
- Practice address
- 805 North Dickinson Drive
Rusk, TX 75785 - Phone
- (903) 683-7201
- Fax
- (903) 683-7199
- NPI assigned
- Feb 27, 2013
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Psychiatric/Mental Health Nurse Practitioner | 363LP0808X | 763777 | TX | Primary |
Addresses
Primary practice location
805 North Dickinson Drive
Rusk, TX 75785
Mailing address
805 North Dickinson Drive
Rusk, TX 75785
Phone (903) 683-7201
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 763777 | Other | TX | STATE LICENSE |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Nurse Practitioner
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 763777 | TX | MD | Psychiatric/Mental Health Nurse Practitioner |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1361923200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1400457600000",
"number": "1770823759",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "805 NORTH DICKINSON DRIVE",
"city": "RUSK",
"state": "TX",
"postal_code": "75785",
"telephone_number": "903-683-7201",
"fax_number": "903-683-7199"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "805 NORTH DICKINSON DRIVE",
"city": "RUSK",
"state": "TX",
"postal_code": "75785",
"telephone_number": "903-683-7201",
"fax_number": "903-683-7199"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WAGGONER",
"first_name": "KRISTINA",
"middle_name": "L",
"credential": "PMHNP-BC",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2013-02-27",
"last_updated": "2014-05-19",
"status": "A"
},
"taxonomies": [
{
"code": "363LP0808X",
"taxonomy_group": "",
"desc": "Nurse Practitioner, Psychiatric/Mental Health",
"state": "TX",
"license": "763777",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "STATE LICENSE",
"identifier": "763777",
"state": "TX"
}
],
"endpoints": [],
"other_names": []
}Other providers in Rusk, TX
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 19, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.