Provider Demographics
NPI:1447894050
Name:WAGNON, HILLARY
Entity type:Individual
Prefix:MRS
First Name:HILLARY
Middle Name:
Last Name:WAGNON
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:HILLARY
Other - Middle Name:
Other - Last Name:TERRILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1712 STUMPF BLVD
Mailing Address - Street 2:
Mailing Address - City:TERRYTOWN
Mailing Address - State:LA
Mailing Address - Zip Code:70056-3923
Mailing Address - Country:US
Mailing Address - Phone:985-893-2845
Mailing Address - Fax:504-893-2654
Practice Address - Street 1:5931 BULLARD AVE STE 6
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70128-2817
Practice Address - Country:US
Practice Address - Phone:504-243-6777
Practice Address - Fax:504-243-6736
Is Sole Proprietor?:No
Enumeration Date:2019-11-06
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA09631225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA09631OtherSTATE LICENSE