Healthcare Provider Details

I. General information

NPI: 1861332363
Provider Name (Legal Business Name): DEVIN NICHOLE WAGNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2026
Last Update Date: 04/01/2026
Certification Date: 04/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 INDUSTRIAL DR
FENNIMORE WI
53809-9578
US

IV. Provider business mailing address

6271 BLUFF RD
LANCASTER WI
53813-9577
US

V. Phone/Fax

Practice location:
  • Phone: 608-822-3276
  • Fax:
Mailing address:
  • Phone: 608-723-9709
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number1910064580
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: