Provider Demographics
NPI:1205410040
Name:WAGNER, RANDI L (APNP)
Entity Type:Individual
Prefix:
First Name:RANDI
Middle Name:L
Last Name:WAGNER
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:RANDI
Other - Middle Name:L
Other - Last Name:ULLRICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:342 N WATER ST STE 600
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-5715
Mailing Address - Country:US
Mailing Address - Phone:651-342-1039
Mailing Address - Fax:651-342-1428
Practice Address - Street 1:342 N WATER ST STE 600
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-5715
Practice Address - Country:US
Practice Address - Phone:651-342-1039
Practice Address - Fax:651-342-1428
Is Sole Proprietor?:No
Enumeration Date:2021-05-07
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10938-33363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner