Provider Demographics
NPI:1255487286
Name:WAGNER, TERESA MICHELLE (PT)
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:MICHELLE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 SOUTH BLVD
Mailing Address - Street 2:
Mailing Address - City:CHIPLEY
Mailing Address - State:FL
Mailing Address - Zip Code:32428-1624
Mailing Address - Country:US
Mailing Address - Phone:850-638-3075
Mailing Address - Fax:850-415-1967
Practice Address - Street 1:807 N TYNDALL PKWY
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32404-9495
Practice Address - Country:US
Practice Address - Phone:850-763-0505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT16007225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY8622OtherBCBS
FLY8622OtherBCBS