Healthcare Provider Details

I. General information

NPI: 1588154967
Provider Name (Legal Business Name): SVITLANA O WAGNER MSN, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2018
Last Update Date: 09/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2852 TAMIAMI TRL STE 5
PORT CHARLOTTE FL
33952-5100
US

IV. Provider business mailing address

2852 TAMIAMI TRL STE 5
PORT CHARLOTTE FL
33952-5100
US

V. Phone/Fax

Practice location:
  • Phone: 941-625-9494
  • Fax: 941-743-8562
Mailing address:
  • Phone: 941-625-9494
  • Fax: 941-743-8562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9315982
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: