Healthcare Provider Details

I. General information

NPI: 1801705074
Provider Name (Legal Business Name): DIANE ELIZABETH WAGNER LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2026
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 OLD SEWARD HWY STE 300
ANCHORAGE AK
99503-6079
US

IV. Provider business mailing address

4000 OLD SEWARD HWY STE 300
ANCHORAGE AK
99503-6079
US

V. Phone/Fax

Practice location:
  • Phone: 907-770-0862
  • Fax:
Mailing address:
  • Phone: 907-770-0862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number253900
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: