Healthcare Provider Details

I. General information

NPI: 1508370651
Provider Name (Legal Business Name): CHRISTA M WAGNON RN, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2017
Last Update Date: 07/01/2021
Certification Date: 07/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7330 N 99TH AVE STE 325
GLENDALE AZ
85307-3022
US

IV. Provider business mailing address

3815 E BELL RD STE 2200
PHOENIX AZ
85032-2139
US

V. Phone/Fax

Practice location:
  • Phone: 480-840-1769
  • Fax: 480-840-1785
Mailing address:
  • Phone: 602-633-3884
  • Fax: 602-633-3841

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP-03457
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCNP-03457
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: