Provider Demographics
NPI:1144803792
Name:WAGNER, STEPHANIE LYNN (RN)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYNN
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 1:156 MAGNOLIA LN
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07748-1859
Mailing Address - Country:US
Mailing Address - Phone:732-433-8651
Mailing Address - Fax:
Practice Address - Street 1:733 N BEERS ST
Practice Address - Street 2:
Practice Address - City:HOLMDEL
Practice Address - State:NJ
Practice Address - Zip Code:07733-1528
Practice Address - Country:US
Practice Address - Phone:732-739-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-02
Last Update Date:2021-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR10508500163WS0121X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WS0121XNursing Service ProvidersRegistered NursePlastic SurgeryGroup - Single Specialty