Healthcare Provider Details

I. General information

NPI: 1386092336
Provider Name (Legal Business Name): ELIZABETH ANN WAGNER AGNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2016
Last Update Date: 04/17/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BARNES JEWISH HOSPITAL PLZ DIV IM CARDIOLOGY
SAINT LOUIS MO
63110-1003
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-1291
  • Fax: 314-362-4278
Mailing address:
  • Phone: 314-362-1291
  • Fax: 314-362-4278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2016015963
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2016015963
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: