Healthcare Provider Details

I. General information

NPI: 1407687627
Provider Name (Legal Business Name): ADELINE WAGNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2024
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 BOULDERS PKWY STE 100A
NORTH CHESTERFIELD VA
23225-4067
US

IV. Provider business mailing address

PO BOX 715868
PHILADELPHIA PA
19171-5868
US

V. Phone/Fax

Practice location:
  • Phone: 804-379-9086
  • Fax: 804-267-1673
Mailing address:
  • Phone: 804-915-1910
  • Fax: 804-968-1803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0119010516
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: