Provider Demographics
NPI:1215227426
Name:WAGONER, MARY G (ARNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:G
Last Name:WAGONER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5950 S FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-2532
Mailing Address - Country:US
Mailing Address - Phone:407-438-3557
Mailing Address - Fax:407-438-3558
Practice Address - Street 1:5950 S FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2532
Practice Address - Country:US
Practice Address - Phone:407-438-3557
Practice Address - Fax:407-438-3558
Is Sole Proprietor?:No
Enumeration Date:2011-04-10
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9232495363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics