Provider Demographics
NPI:1154093664
Name:WAGNER, DANIELLE (APRN)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1290 SILAS DEANE HWY
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-4337
Mailing Address - Country:US
Mailing Address - Phone:860-972-5663
Mailing Address - Fax:860-545-2882
Practice Address - Street 1:65 MEMORIAL RD STE 405
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-4219
Practice Address - Country:US
Practice Address - Phone:860-972-1506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-03
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT10086363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily