Healthcare Provider Details

I. General information

NPI: 1477596468
Provider Name (Legal Business Name): ELIZABETH MARIE WAGNER RN, MSN, CPNP-AC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 03/13/2023
Certification Date: 03/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 CHICAGO AVE # MS 324203
MINNEAPOLIS MN
55404-4518
US

IV. Provider business mailing address

1019 DANUBE AVE
SHAKOPEE MN
55379-4636
US

V. Phone/Fax

Practice location:
  • Phone: 126-813-7336
  • Fax: 612-813-7660
Mailing address:
  • Phone: 612-813-7336
  • Fax: 612-813-7336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number41272234
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: