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General NPI Number Information
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NPI Number | 1043738214
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Entity Type | Individual
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Provider Name | CARLY JEAN WAGNER NP
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Gender | Female
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Dates
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Enumeration Date | 09/07/2017
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Last Update Date | 08/16/2023
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Provider Practice Location Address
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Address Line | 50 IRVING ST NW
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City | WASHINGTON
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State | DC
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Zip | 20422-0001
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Country | US
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Telephone | 202-717-6846
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Fax | 830-239-9756
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Provider Business Mailing Address
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Address Line | 50 IRVING ST NW
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City | WASHINGTON
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State | DC
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Zip | 20422-0001
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Country | US
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Telephone | 202-745-8000
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 0024175304
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License Number State | VA
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