Provider Demographics
NPI:1275768558
Name:WAGNER, SUSAN J (COMMUNITY HEALTH WOR)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:J
Last Name:WAGNER
Suffix:
Gender:F
Credentials:COMMUNITY HEALTH WOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BOX 130
Mailing Address - Street 2:
Mailing Address - City:NEW KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12459
Mailing Address - Country:US
Mailing Address - Phone:845-586-4194
Mailing Address - Fax:
Practice Address - Street 1:278 JOHN TUTTLE RD
Practice Address - Street 2:
Practice Address - City:NEW KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12459
Practice Address - Country:US
Practice Address - Phone:845-586-4194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-15
Last Update Date:2009-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker