Provider Demographics
NPI:1114562097
Name:WAGNER, NICOLE KRISTIN (RPH)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:KRISTIN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17105 SAN CARLOS BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33931-5305
Mailing Address - Country:US
Mailing Address - Phone:239-340-7073
Mailing Address - Fax:
Practice Address - Street 1:17105 SAN CARLOS BLVD
Practice Address - Street 2:
Practice Address - City:FORT MYERS BEACH
Practice Address - State:FL
Practice Address - Zip Code:33931-5305
Practice Address - Country:US
Practice Address - Phone:239-340-7073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-14
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS29977183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist