Healthcare Provider Details

I. General information

NPI: 1568822559
Provider Name (Legal Business Name): ELIZABETH WAGNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2016
Last Update Date: 03/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8771 WESTPOINTE DR
INDIANAPOLIS IN
46231-1169
US

IV. Provider business mailing address

8771 WESTPOINTE DR
INDIANAPOLIS IN
46231-1169
US

V. Phone/Fax

Practice location:
  • Phone: 317-248-9299
  • Fax:
Mailing address:
  • Phone: 317-248-9299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number16-012027-1
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: