Healthcare Provider Details

I. General information

NPI: 1245174705
Provider Name (Legal Business Name): CHEYENNE NICOLE WAGEMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2026
Last Update Date: 04/15/2026
Certification Date: 04/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5168 BROWNS CREEK RD
SAINT ALBANS WV
25177-8775
US

IV. Provider business mailing address

5168 BROWNS CREEK RD
SAINT ALBANS WV
25177-8775
US

V. Phone/Fax

Practice location:
  • Phone: 304-951-3194
  • Fax:
Mailing address:
  • Phone: 304-951-3194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License NumberF721332
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: