Provider Demographics
NPI:1073758751
Name:BELLEVUE, WAGNER (LPN)
Entity Type:Individual
Prefix:MR
First Name:WAGNER
Middle Name:
Last Name:BELLEVUE
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 JEFFERSON PLZ
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601-4035
Mailing Address - Country:US
Mailing Address - Phone:845-473-5900
Mailing Address - Fax:845-473-6692
Practice Address - Street 1:4 JEFFERSON PLZ
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-4035
Practice Address - Country:US
Practice Address - Phone:845-473-5900
Practice Address - Fax:845-473-6692
Is Sole Proprietor?:No
Enumeration Date:2008-12-09
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY275093164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse