=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366419087
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAROLYN WAGNER NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2006
-----------------------------------------------------
Last Update Date | 03/10/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1770 E LAKE SHORE DR SUITE 207
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62521-3832
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-429-9700
-----------------------------------------------------
Fax | 217-429-9702
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1770 E LAKE SHORE DR SUITE 207
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62521-3832
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-429-9700
-----------------------------------------------------
Fax | 217-429-9702
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 209-001389
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------