MEDICARE: JEANNE WAGONER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	34778885	OH

General Provider Information

NPI Number	:	1760880314
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEANNE WAGONER

Provider Business Mailing Address
First Line	:	17556 FAIRLAWN DR
Second Line	:
City	:	CHAGRIN FALLS
State	:	OH
Zip	:	44023-6419
Country	:	US
Telephone Number	:	216-320-3136
Fax Number	:

Provider Business Practice Location Address
First Line	:	2400 ROXBORO RD
Second Line	:
City	:	CLEVELAND HTS
State	:	OH
Zip	:	44106-3624
Country	:	US
Telephone Number	:	216-320-3136
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/15/2014
Last Update Date	:	12/15/2014

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Directions to “ JEANNE WAGONER ” Practice Location

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