Healthcare Provider Details

I. General information

NPI: 1033469994
Provider Name (Legal Business Name): CHRISTINA J WAGENER APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2012
Last Update Date: 12/13/2025
Certification Date: 12/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5419 135TH ST
CRESTWOOD IL
60418-1529
US

IV. Provider business mailing address

5419 135TH ST
CRESTWOOD IL
60418-1529
US

V. Phone/Fax

Practice location:
  • Phone: 708-358-7300
  • Fax:
Mailing address:
  • Phone: 708-358-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number277000049
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.0040625
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71017358A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN.31164
License Number StateSC
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4048488
License Number StateKY
# 6
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number277000049
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: