Provider Demographics
NPI:1063018802
Name:WAGNER, TERESA GAIL
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:GAIL
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 DOTSON CT APT 23
Mailing Address - Street 2:
Mailing Address - City:SUMMERSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26651-1767
Mailing Address - Country:US
Mailing Address - Phone:304-880-0996
Mailing Address - Fax:304-471-2488
Practice Address - Street 1:101 2ND ST STE 201
Practice Address - Street 2:
Practice Address - City:SUTTON
Practice Address - State:WV
Practice Address - Zip Code:26601-1303
Practice Address - Country:US
Practice Address - Phone:304-765-3668
Practice Address - Fax:304-765-3697
Is Sole Proprietor?:No
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker