Healthcare Provider Details

I. General information

NPI: 1427412733
Provider Name (Legal Business Name): STEPHANIE LYNN WAGNER BSN, RNC, IBCLC, RLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2016
Last Update Date: 04/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 E 119TH ST APT 8B
NEW YORK NY
10035-4080
US

IV. Provider business mailing address

181 E 119TH ST APT 8B
NEW YORK NY
10035-4080
US

V. Phone/Fax

Practice location:
  • Phone: 571-212-7673
  • Fax:
Mailing address:
  • Phone: 571-212-7673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-66565
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: