Healthcare Provider Details

I. General information

NPI: 1093881666
Provider Name (Legal Business Name): MONA H WAGNER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 04/06/2023
Certification Date: 04/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-3003
US

IV. Provider business mailing address

PO BOX 714960
COLUMBUS OH
43271-4960
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-8610
  • Fax:
Mailing address:
  • Phone: 205-322-1808
  • Fax: 205-322-1851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number9418194
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN9418194
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number25214
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: