Provider Demographics
NPI:1124581855
Name:WAGNER, SHARON DARLENE
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:DARLENE
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:PO BOX 167
Mailing Address - Street 2:
Mailing Address - City:PINE HALL
Mailing Address - State:NC
Mailing Address - Zip Code:27042-0167
Mailing Address - Country:US
Mailing Address - Phone:336-750-7410
Mailing Address - Fax:
Practice Address - Street 1:440 INGRAM DR
Practice Address - Street 2:
Practice Address - City:KING
Practice Address - State:NC
Practice Address - Zip Code:27021-8208
Practice Address - Country:US
Practice Address - Phone:336-983-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-10
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11693224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant