Healthcare Provider Details

I. General information

NPI: 1710260567
Provider Name (Legal Business Name): DANA WAGNER CPHT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2011
Last Update Date: 09/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 CHAUVET RD
GLEN ELLEN CA
95442-1111
US

IV. Provider business mailing address

PO BOX 1111
GLEN ELLEN CA
95442-1111
US

V. Phone/Fax

Practice location:
  • Phone: 707-490-9227
  • Fax:
Mailing address:
  • Phone: 707-490-9227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: