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General NPI Number Information
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NPI Number | 1417683277
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Entity Type | Individual
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Provider Name | SOPHIA COLLETTE WAGNER
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Gender | Female
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Dates
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Enumeration Date | 07/25/2022
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Last Update Date | 09/15/2022
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Provider Practice Location Address
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Address Line | 4320 HOUMA BLVD FL 5
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City | METAIRIE
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State | LA
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Zip | 70006-2961
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Country | US
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Telephone | 504-503-6565
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Fax | 504-456-8053
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Provider Business Mailing Address
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Address Line | 4200 HOUMA BLVD
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City | METAIRIE
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State | LA
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Zip | 70006-2970
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Country | US
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Telephone | 504-503-6781
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 226793
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License Number State | LA
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