MEDICARE: SVITLANA O WAGNER MSN, FNP

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	363LF0000X	Family Nurse Practitioner	ARNP9315982	FL

General Provider Information

NPI Number	:	1588154967
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SVITLANA O WAGNER MSN, FNP

Provider Business Mailing Address
First Line	:	2852 TAMIAMI TRL STE 5
Second Line	:
City	:	PORT CHARLOTTE
State	:	FL
Zip	:	33952-5100
Country	:	US
Telephone Number	:	941-625-9494
Fax Number	:	941-743-8562

Provider Business Practice Location Address
First Line	:	2852 TAMIAMI TRL STE 5
Second Line	:
City	:	PORT CHARLOTTE
State	:	FL
Zip	:	33952-5100
Country	:	US
Telephone Number	:	941-625-9494
Fax Number	:	941-743-8562

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

Provider Enumeration Date	:	05/11/2018
Last Update Date	:	09/10/2018

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