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General NPI Number Information
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NPI Number | 1821602947
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Entity Type | Individual
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Provider Name | HAILEY LYNN WAGNER PT, DPT
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Gender | Female
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Dates
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Enumeration Date | 09/04/2020
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Last Update Date | 02/21/2025
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Provider Practice Location Address
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Address Line | 1950 BLUEWATER BLVD STE 100
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City | NICEVILLE
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State | FL
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Zip | 32578-3888
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Country | US
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Telephone | 850-807-4200
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Fax |
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Provider Business Mailing Address
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Address Line | 1100 CIRCLE 75 PKWY SE STE 1400
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City | ATLANTA
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State | GA
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Zip | 30339-3067
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Country | US
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Telephone | 678-981-3543
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Fax | 404-777-1311
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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 | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | PT36009
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT36009
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License Number State | FL
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