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General NPI Number Information
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NPI Number | 1760910814
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Entity Type | Individual
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Provider Name | FRANCES MARIE WAGNER
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Gender | Female
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Dates
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Enumeration Date | 06/01/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 12720 LINCOLN LAKE AVE
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City | GOWEN
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State | MI
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Zip | 49326-9403
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Country | US
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Telephone | 616-548-2838
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Fax |
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Provider Business Mailing Address
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Address Line | 12720 LINCOLN LAKE AVE
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City | GOWEN
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State | MI
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Zip | 49326-9403
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Country | US
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Telephone | 616-548-2838
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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 | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number | AF410215936
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License Number State | MI
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