Healthcare Provider Details

I. General information

NPI: 1215515549
Provider Name (Legal Business Name): SHELBY WAGNER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHELBY HAMMONDS

II. Dates (important events)

Enumeration Date: 03/30/2021
Last Update Date: 01/11/2023
Certification Date: 01/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 HOME ST
GEORGETOWN OH
45121-1407
US

IV. Provider business mailing address

615 ELSINORE PL
CINCINNATI OH
45202-1459
US

V. Phone/Fax

Practice location:
  • Phone: 513-834-7063
  • Fax:
Mailing address:
  • Phone: 513-834-7063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.450700
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: