Provider Demographics
NPI:1033188412
Name:WAGNER, JENNIFER ANN (RN)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ANN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W4247 JUNIPER DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WI
Mailing Address - Zip Code:53566-8543
Mailing Address - Country:US
Mailing Address - Phone:608-325-6578
Mailing Address - Fax:
Practice Address - Street 1:1550 WILDWOOD DR
Practice Address - Street 2:
Practice Address - City:PLAIN
Practice Address - State:WI
Practice Address - Zip Code:53577-9644
Practice Address - Country:US
Practice Address - Phone:608-546-9834
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse