Healthcare Provider Details

I. General information

NPI: 1255808002
Provider Name (Legal Business Name): VICKI LYNN WAGNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2018
Last Update Date: 10/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 4TH ST NE
AUBURN WA
98002-5020
US

IV. Provider business mailing address

502 4TH ST NE
AUBURN WA
98002-5020
US

V. Phone/Fax

Practice location:
  • Phone: 253-931-4990
  • Fax:
Mailing address:
  • Phone: 253-931-4990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License NumberRN00077448
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: