Healthcare Provider Details

I. General information

NPI: 1184872418
Provider Name (Legal Business Name): DEBRA LYNN WAGNER CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2008
Last Update Date: 11/23/2020
Certification Date: 11/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11700 N MERIDIAN ST # C240 CENTER FOR CHILDREN'S CANCER AND BLOOD DISEASES
CARMEL IN
46032-4656
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-688-4673
  • Fax: 317-688-3436
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number71000837A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: