Healthcare Provider Details

I. General information

NPI: 1437483245
Provider Name (Legal Business Name): MRS. JANET WAGNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2009
Last Update Date: 08/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 OLD COUNTY RD 128
JEFFERSONVILLE NY
12748
US

IV. Provider business mailing address

PO BOX 412
JEFFERSONVILLE NY
12748-0412
US

V. Phone/Fax

Practice location:
  • Phone: 845-807-1132
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number006077-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: