Healthcare Provider Details

I. General information

NPI: 1952422263
Provider Name (Legal Business Name): SANDRA WAGNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 HANOVER ST SUITE 2
LEBANON NH
03766-1312
US

IV. Provider business mailing address

140 NORTH ST
CLAREMONT NH
03743-2038
US

V. Phone/Fax

Practice location:
  • Phone: 603-448-0126
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number045866-21
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: