Provider Demographics
NPI:1003013525
Name:WAGSCHAL, NICOLE MARILYN (MSN APRN)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARILYN
Last Name:WAGSCHAL
Suffix:
Gender:F
Credentials:MSN APRN
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MARILYN
Other - Last Name:TUBBS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN CRNP
Mailing Address - Street 1:150 BALAZS RD
Mailing Address - Street 2:
Mailing Address - City:WILLINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06279-2401
Mailing Address - Country:US
Mailing Address - Phone:866-389-2727
Mailing Address - Fax:
Practice Address - Street 1:3514 MAIN ST
Practice Address - Street 2:CVS- MINUTE CLINIC
Practice Address - City:COVENTRY
Practice Address - State:CT
Practice Address - Zip Code:06238-1551
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005423363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily