MEDICARE: BRENDA L WAGER FNP-C

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	363LF0000X	Family Nurse Practitioner	209.014538	IL

General Provider Information

NPI Number	:	1851846109
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENDA L WAGER FNP-C

Provider Business Mailing Address
First Line	:	11630 E 1300TH ST # 2
Second Line	:
City	:	CAMBRIDGE
State	:	IL
Zip	:	61238-9446
Country	:	US
Telephone Number	:	309-937-1919
Fax Number	:

Provider Business Practice Location Address
First Line	:	11630 E 1300TH ST
Second Line	:
City	:	CAMBRIDGE
State	:	IL
Zip	:	61238-9446
Country	:	US
Telephone Number	:	309-937-1919
Fax Number	:

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

Provider Enumeration Date	:	08/16/2016
Last Update Date	:	05/10/2021

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