Healthcare Provider Details

I. General information

NPI: 1295914331
Provider Name (Legal Business Name): COURTNEY LEE WAGNER LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2007
Last Update Date: 10/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6261 OLD BETHEL RD
CRESTVIEW FL
32536-5507
US

IV. Provider business mailing address

221 HOSPITAL DR NE
FORT WALTON BEACH FL
32548-5066
US

V. Phone/Fax

Practice location:
  • Phone: 850-683-7500
  • Fax: 850-683-7523
Mailing address:
  • Phone: 850-833-9240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN5178468
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: