Provider Demographics
NPI:1275125635
Name:WAGNER, BRIANNA
Entity Type:Individual
Prefix:
First Name:BRIANNA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRIANNA
Other - Middle Name:
Other - Last Name:COOK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1084 SW BENCHOR AVE
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-3424
Mailing Address - Country:US
Mailing Address - Phone:772-301-4566
Mailing Address - Fax:
Practice Address - Street 1:1084 SW BENCHOR AVE
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-3424
Practice Address - Country:US
Practice Address - Phone:772-301-4566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-08
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Single Specialty