MEDICARE: ELIZABETH WAGNER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172V00000X	Community Health Worker	16-012027-1	IN

General Provider Information

NPI Number	:	1568822559
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH WAGNER

Provider Business Mailing Address
First Line	:	8771 WESTPOINTE DR
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46231-1169
Country	:	US
Telephone Number	:	317-248-9299
Fax Number	:

Provider Business Practice Location Address
First Line	:	8771 WESTPOINTE DR
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46231-1169
Country	:	US
Telephone Number	:	317-248-9299
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/03/2016
Last Update Date	:	03/03/2016

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