Provider Demographics
NPI:1285202606
Name:WAGNER, CYNTHIA YVONNE
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:YVONNE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20198 US HIGHWAY 68
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45118-9781
Mailing Address - Country:US
Mailing Address - Phone:513-314-0190
Mailing Address - Fax:
Practice Address - Street 1:303 N HURSTBOURNE PKWY STE 200
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-5158
Practice Address - Country:US
Practice Address - Phone:513-314-0190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-13
Last Update Date:2021-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.296716163WG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0600XNursing Service ProvidersRegistered NurseGerontology