Healthcare Provider Details

I. General information

NPI: 1417598491
Provider Name (Legal Business Name): MELISSA ANNE WAGNER CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELISSA ANNE GONDER CRNP

II. Dates (important events)

Enumeration Date: 10/01/2019
Last Update Date: 09/10/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 WEST MAIN ST
SILVERDALE PA
18962
US

IV. Provider business mailing address

164 WEST MAIN ST
SILVERDALE PA
18962
US

V. Phone/Fax

Practice location:
  • Phone: 215-258-3810
  • Fax: 833-616-9320
Mailing address:
  • Phone: 215-258-3810
  • Fax: 833-616-9320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP020001
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: