Healthcare Provider Details

I. General information

NPI: 1972435402
Provider Name (Legal Business Name): OLIVIA ANN WAGONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 05/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11080 HALL RD STE A
STERLING HEIGHTS MI
48314-1511
US

IV. Provider business mailing address

1851 VILLAGE GREEN BLVD APT 207
ROCHESTER HILLS MI
48307-6102
US

V. Phone/Fax

Practice location:
  • Phone: 586-254-7200
  • Fax:
Mailing address:
  • Phone: 330-888-8050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number1601001237
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: