Healthcare Provider Details

I. General information

NPI: 1760091581
Provider Name (Legal Business Name): SHONNA MARIE WAGAMAN FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2020
Last Update Date: 09/09/2020
Certification Date: 09/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23000 MOAKLEY ST STE 206
LEONARDTOWN MD
20650-2917
US

IV. Provider business mailing address

2 PARK CENTER CT STE 200
OWINGS MILLS MD
21117-4221
US

V. Phone/Fax

Practice location:
  • Phone: 410-571-2946
  • Fax: 301-632-6187
Mailing address:
  • Phone: 410-571-2946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR212454
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: