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General NPI Number Information
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NPI Number | 1336543974
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Entity Type | Individual
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Provider Name | DEBORAH JEAN WAGNER CRNP
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Gender | Female
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Dates
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Enumeration Date | 10/10/2014
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Last Update Date | 12/21/2018
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Provider Practice Location Address
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Address Line | 8010 MEMORIAL PKWY SW
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City | HUNTSVILLE
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State | AL
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Zip | 35802-3039
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Country | US
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Telephone | 256-489-3192
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Fax | 256-489-3196
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Provider Business Mailing Address
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Address Line | 8010 MEMORIAL PKWY SW
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City | HUNTSVILLE
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State | AL
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Zip | 35802-3039
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Country | US
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Telephone | 256-489-3192
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Fax | 256-489-3196
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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 | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | 1-039213
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License Number State | AL
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